Standard Operating Procedure for Mental Health Home Treatment Team

Transcription

1 Standard Operating Procedure for Mental Health Home Treatment Team Version Number: V1 Name of originator/author: Urgent Care Service Manager, Consultant Psychiatrist Clinical Lead Urgent Care Name of responsible committee: Clinical Governance Committee Name of executive lead: Chief Nurse and Director of Quality Assurance Date V1 issued: February 2014 Last Reviewed: February 2014 Next Review date: February 2017 Scope: Trust wide MMHSCT Document Code CL83 1

2 Document Control Sheet Document Title / Ref: Lead Executive Director Author and Contact Number Type of Document Document Purpose Mental Health Home Treatment Team Standard Operating Procedures Chief Nurse and Director of Quality Assurance Urgent Care Service Manager, Consultant Psychiatrist Clinical Lead Urgent Care Standard Operating Procedure Broad Category Clinical This standard operating procedure aims to ensure that all Trust staff involved in the provision of the Mental Health Home Treatment service understand and are working together towards an effective coordinated service that meets the individual needs of service users, as well as those of their relative/carer(s). Scope Trust wide Version number 1 Consultation Mental Health Home Treatment Team service, Inpatients, Community, Head of Nursing, Operational Management Team, Clinical Risk Committee, Heads of Professions. Approving Committee Clinical Risk Committee Approval Date March 2014 Ratification Lead Executive Approval 13 March 2014 and Date V1 Valid from Date February 2014 Current version is valid from approval date Date of Last Review February 2014 Date of Next Review February 2017 Procedural Documents to be read in conjunction with this document: The Guidelines for the Physical Assessment of Service User. Assessment, Care and Support Planning Policy and Procedure for Care Programme Approach (CPA) and Non CPA. Medicines Policy. Slips, Trips and Falls policy. Absent Without Leave Policy (including procedure for missing persons). Relevant Mental Health Act Policies. Clinical Handover of Care Policy. Safeguarding. Training Needs Analysis Impact There are no training requirements for this procedural document. Awareness ½ day events to be held for each of the 3 teams to support implementation. Financial Resource Impact There are no financial resource impacts. Document Change History Changes to this document in different versions must be detailed below. Rationale for the change should also be given. Version Number / Name of procedural document this supersedes Type of Change i.e. Review / Legislation / Claim / Complaint Date Details of Change and approving group or Executive Lead (if done outside of the formal revision process). 2

3 External references used in the creation of this document: If these include monitoring duties upon the Trust for this policy the specific details should be recorded on the Monitoring and Compliance Requirements sheet. Privacy Impact N/a Any issues? Choose an item. Assessment submitted Fraud Proofing N/a Any issues? Choose an item. submitted If not relevant to this procedural document give rationale: Policy authors are asked to consider each of the nine protected characteristics under the Equality Act We expect you to demonstrate that throughout the policy process you have had regard to the aims of the Equality Duty: 1. Eliminate unlawful discrimination, harassment and victimisation and any other conduct prohibited by the act. 2. Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and 3. Foster good relations between people who share a protected characteristic and people who do not share it. Please provide a brief account of how you have done this, further work to be completed and any support you have had in considering the aims and working in compliance with the Equality Duty. If you are unclear on how to do this or would like further advice and support then you may contact [email protected]. It is the responsibility of the approving group to ensure this statement reflects the Trusts objectives and position with compliance as set out within the NHS Equality Delivery System. This standard operating procedure is broad and the scope is Trust Wide so complies with the Trust s Equality Delivery System. This procedure is aligned to the Trust s Admission, Discharge and Transfer Policy and is therefore compliant with Trust s Equality Delivery System. In line with the Trust values we may publish this document on our External Website. Is there any reason you would prefer this is not done? No It is the Authors responsibility to ensure all procedural documents comply with the Trust values If you are unclear on any of the requirements in the document control sheet then please [email protected] before proceeding. 3

4 Monitoring and Compliance Requirements Sheet For Audit, Registration and NHSLA purposes all procedural documents must have monitoring requirements or key performance indicators set by the authors, Committees or Lead Directors. This allows the Trust to routinely monitor the effectiveness and impact of their procedural documents on a regular basis. Procedural Document Title: Mental Health Home Treatment Team Standard Operating Procedures an Appendix to the Trust s Admission, Discharge and Transfer Policy. Does this procedural document offer support or evidence for the Trusts registered activities and outcomes? Yes Primarily Outcome 4 Care and Welfare of People who use services Additional Outcome 16 Assessing and Monitoring Quality Is this an NHSLA Document? Yes Which Standard does this relate to? 4 - Safe Environment Which Criterion 4/10 Discharge Choose an item. Choose an item. If other Monitoring requirements are necessary i.e. Health & Safety Act and you should include them here and record them in the External References section Specify where the requirement originates Minimum Requirement / Standard / Indicator to be monitored & Section of document it appears Level 1 a. The documented process to include discharge requirements for all patients. Care Quality Commission (2010), Essential Standards of Quality and Safety, CQC, London Department of Health (2008), Mental Health Act 1983 and Mental Health Act Code of Practice, DoH, London Department of Health (2007) Mental Capacity Act Code of Practice, DoH, London National Confidential Inquiry Into Suicide and Homicide by people with Mental Illness, Safer Mental Health Services: a toolkit (November 2012) Care Services Improvement Partnership (2007), A Positive Outlook: A good practice toolkit to improve discharge from inpatient mental health care, DoH, London Process for monitoring Review Responsible Individual / Group Urgent Care Service Manager and Head of Nursing Additional Details i.e. Section number, Code of Practice Frequency of Monitoring Responsible Group for review of results / action plan approval / implementation Comments 3 yearly Clinical Governance Committee Section 3 page 11 Review Urgent Care Service Manager and 3 Yearly Clinical Governance Committee Section 7 Page 17 4

5 b. The documented process to include information to be given to the receiving healthcare professional c. The documented process to include information to be given to the patient when they are discharged Review Head of Nursing Section 8 Page 18 Section 11 page 22 Section 12 Page 24 Appendix 3 Page 40 Urgent Care Service Manager and 3 Yearly Clinical Governance Committee Section 13 Page 25 Head of Nursing d. The documented process to include how a patient s medicines are managed on discharge e. The documented process to include how the organisation records the information given in minimum requirements b) and c) f. The documented process to include out of hours discharge process g. The documented process to include how the Trust monitors compliance with all of the above. Monitoring Compliance page 4 of this policy. Review Urgent Care Service Manager and Head of Nursing 3 Yearly Clinical Governance Committee Section 8.3 of Medicines Policy Page 26. And SOP 35 of Medicines Policy. Section 13.7 of this policy. Appendix 3 Discharge checklist of this policy. Review Matrons and Head of Nursing 3 Yearly Clinical Governance Committee Section 13.3 page 25 of this policy. Review Matrons and Head of Nursing 3 Yearly Clinical Governance Committee Standard Operating Procedure Appendix 5 of this policy. Review Matrons and Head of Nursing Yearly Clinical Governance Committee Audit of discharge process annually. 7 day follow up Report plus reports to Trust Board. NB: If you have selected audit you should complete the required audit registration form and standards document and submit these with your expected timescales for completing the audit to [email protected] as soon as possible and no later than 4 weeks prior to the audit commencing. The Group / Committee should also ensure the monitoring work is added to their yearly schedule of monitoring and action logs as appropriate. 5

6 Section Title Page Number 1 Introduction 7 2 Service Coverage 7 3 Our Shared Trust Values 8 4 Mission Statement Urgent Care Mission Statement Mental Health Home Treatment Team Mission Statement 8 5 Service Aims 8 6 Service Objectives 9 7 Key Performance Indicators 9 8 Service Criteria 9 9 Referral Process New referrals Service Users known to the Trust Gate-keeping Referrals Direct Admissions Referral Guidance Self Referrals Assessment Early Discharge Planning Care Planning Home Based Treatment Review Zoning Zoning Definition Delayed Discharges Discharge Planning Discharge from Trust Services Transfer to In Patient Services Crisis Line Interface with Services Team Capacity Capacity Management Medical Cover in Mental Health Home Treatment Team 16 Appx 1 Flow chart to support guidance on delivery of gate-keeping by the MMHHT. 17 Appx 2 Protocol for MHHTT Assessment and Gate-Keeping 18 Appx 3 Admission Notification template 20 Appx 4 MHHTT Admission and Discharge Checklist 21 Appx 5 Role of the Named Worker 23 Appx 6 Guidance on Zoning 24 Appx 7 Discharge Notification template 25 Appx 8a Guidance for Staff working on the Crisis Line 26 Appx 8 b Crisis Line Escalation 28 Appx 9 Care Pathway 29 Appx 10 Role of the Shift Co-ordinator 32 Appx 11 Contact Details 33 Appx 12 Critical to Quality Measures 34 Page 6 of 36

7 Standard Operating Procedure for Mental Health Home Treatment Team 1. Introduction The Mental Health Home Treatment Teams (MHHTT) are a key step in implementing and delivering on the NHS Plan and the Mental Health National Service Framework. The Mental Health Home Treatment Teams (MHHTT) form an integral part of a whole systems approach to providing specialist services for people experiencing severe and enduring mental health needs that would otherwise require inpatient care. The services offered by the Mental Health Home Treatment Teams, are based on a Recovery and Social Inclusion model, the principles of the Care Programme Approach (CPA), Care Management, and the Department of Health Mental Health Policy Implementation Guidelines. Mental Health Home Treatment Teams form part of Urgent Care Services and are integrated with other services within in Urgent Care. These include Mental Health Liaison Services, SAFIRE rapid assessment unit and Bed Management. MHHTT also have strong links and networks with Inpatient Services and Community Services. This integrated approach aims to ensure a comprehensive and seamless service to users and their carers during periods of psychiatric crisis. 2. Service Coverage There are three Mental Health Home Treatment Teams providing services to the people of Manchester. The service operates a 24hrs, 7 days a week city wide service covering geographical locations with reference to Clinical Commissioning Groups (CCGs). The teams are locality based covering geographical locations in the North, Central and South parts of the city. Between the hours of 9pm and 7am Mental Health Home Treatment Teams operates a citywide service based in the North Mental Health Home Treatment Team office. The purpose of this service is to ensure effective gate keeping and to co ordinate referrals and direct admissions to Mental Health Home Treatment Teams. MHHTT also operates the Trust s Crisis Line. The service is provided for service users under the care of a commissioning GP and resident within a Manchester boundary. For service users with a Manchester GP and not resident within the Trust boundaries, and service users with a non Manchester GP but resident within Trust boundaries, agreement will be reached on a case by case basis. 7

8 3 Our Shared Trust Values Truthfulness To be honest about the service and the time-limited interventions that can be expected by the Service User and Carer (purpose and function). Respect Privacy and dignity of service users will be upheld at all times. Holistic view and valuing difference; opportunities for learning and relapse prevention are maximized by service users and carers involvement in finding the solutions. Understanding Every service user will be dealt with individually and respectfully. Standards A holistic approach to care will be used at all times. Collaborative arrangements for planned discharge are undertaken. To adhere to the quality standards and implement best practice. Togetherness Service users and their families / carers will be encouraged to participate in their assessment and care planning processes. Working with other services to provide a seamless approach to care. 4 Mission Statement 4.1 Urgent Care Mission Statement An integrated service to provide an urgent response to psychiatric emergencies. 4.2 Mental Health Home Treatment Team Mission Statement To provide an urgent response to psychiatric emergencies with the aim of providing home based treatment whenever possible as an alternative to hospital. 5 Service Aims To provide equitable, timely and responsive access across the city 24/7, 365 days a year. To continuously improve the patient experience and aid recovery. To manage people in the least restrictive environment. To work collaboratively with service users and carers. To provide high quality care, which is needs led, and informed by evidence based practice. To provide a multi-disciplinary approach ensuring integrated working with other urgent care, community and inpatient services. 8

9 6 Service Objectives To provide evidence based bio psychosocial assessments and interventions. To provide an out of hours Crisis Line. To work collaboratively with service users and their carer s. To provide clear service user/carer information that promotes choice. To gate-keep all potential admissions to hospital and ensure an alternative to hospital admission is considered. To advise referring bodies of alternative services and act as a source of information for local communities. To provide a response to all urgent referrals within 24 hours. To facilitate admission to hospital when assessed and as required. To facilitate early discharge planning with Inpatient services. To work effectively with other Trust and non Trust services. To work in accordance with evidenced based pathways integrated with other Acute Services in the Trust To work in accordance with standard working practice guidance across the 3 locality teams. To monitor delivery of service impact through an agreed set of Critical to Quality measures. 7 Key performance Indicators Quality and performance of the service is monitored through an agreed set of key indicators informed by the Critical to Quality measures (Refer to Appendix 12 for details) and include: Face to face gate-keeping and % of assessments accepted by Mental Health Home Treatment Team Length of stay Referral to assessment time Re-admissions within 30 days Service user experience Care plans Reporting of these measures is through the Care Group performance reporting processes and the service dashboard. 8 Service Criteria The Mental Health Home Treatment Team provides a home based treatment service for individuals who would otherwise require treatment in a hospital setting. The MHHTT currently provides a service for people aged

10 The Service is not appropriate for individuals with: Primary diagnosis of alcohol or other substance misuse Primary diagnosis of brain damage Other organic disorders including dementia Primary diagnosis of learning disabilities Crisis related solely to relationship issues Mild anxiety disorders People of no abode (must have a temporary address for anticipated duration of treatment with Mental Health Home Treatment Team). OR Where the service user, or their carer/family, is unable or refuses to work with the Mental Health Home Treatment Team. Any significant physical health problems that can t safely managed and treated in a community sitting by appropriate professionals. It is expected that the service will attempt to engage with a service user a minimum of 2 occasions and at least one of these to be a home visit or attempted face to face contact. 9 Referral Process 9.1 New referrals All new referrals to the Mental Health Home Treatment Team are made through the Mental Health Home Treatment Team hub. The practitioner taking the referral will complete the triage tool and where it is agreed as urgent will pass the referral to the Mental Health Home Treatment Team shift coordinator by telephone and fax. The MHHTT hub may complete a face to face assessment on behalf of the MHHTTs. 9.2 Service Users known to the Trust Referrals for service users already known to the Trust can be made directly to the appropriate locality team in person or over the phone. The referrer will contact the shift coordinator by telephone or in person. The shift co-ordinator will complete the triage tool and agree the status of the referral and if urgent arrange joint assessment with the referrer. Where a joint assessment is not possible the Mental Health Home Treatment Team will complete the assessment. Referrals for service users already known to the Trust will be treated as gate keeping referrals. All Urgent Care Services (A & E Liaison Team, Bed Management Team and SAFIRE) can make direct admissions to Mental Health Home Treatment Team. Direct admissions from A & E Liaison will be treated as gate keeping referrals. All internal referrals will be considered gate- keeping referrals and recorded as gate-keeping referrals. This includes referrals from Area Teams, PCMHTs and psychology and Outpatients. 10

11 9.3 Gate- keeping Referrals Referrals for gate keeping should be made as soon as it is identified that an individual may require treatment in hospital and should be made before a request for a Mental Health Act Assessment. Refer to Appendices 1 and 2 for further guidance on gate-keeping referrals and flow chart. 9.4 Direct Admissions Urgent Care Services (SAFIRE, Bed Management and MHLT) can make direct admissions to the Mental Health Home Treatment Team. The referrer should contact the Mental Health Home Treatment Team by phone or in person to discuss the purpose of the admission and agree a care plan. The referrer will document this discussion and the preliminary care plan. Where the referrer and MHHTT staff cannot agree a direct admission, this should be escalated through the line management arrangements. 9.5 Referral Guidance All service users referred to Mental Health Home Treatment Team should have been assessed face to face by the referrer within the previous 24 hours. It is expected that the referrer will have discussed referral to the Mental Health Home Treatment Team with the service user and their family or carer. Mental Health Home Treatment Team staff (or Gateway staff) will agree the appropriateness for assessment with the referring agency. For those service users known to the Trust consideration for referral should be made following indication of early warning signs and include discussion with the Mental Health Home Treatment Team service. Primary Care Mental Health Team, Psychology and Consultant referrals should have received a face to face assessment within the previous 2 weeks and a review within the last 12 hours. Referrals for service users over 65. Service users over the age of 65 who are under the care of the Adults of Working Age Area Teams can be referred to the MHHTT in the usual way. Service Users over the age of 65 who are known to later life services or not known to any service can be referred in certain circumstances and individual cases should be considered on an individual basis. The MHHTT practitioner will request that the risk matrix is updated and a risk follow up completed in order to accept an internal referral/ direct admission. 9.6 Self Referrals Service users who are not already receiving services from the Trust can make a self referral through the Gateway service. 11

12 Service users who are receiving care from the Trust should contact their Care co-ordinator or lead professional where possible before making a self referral. 10 Assessment The service user will normally be offered an assessment within 24 hours of referral. It is the responsibility of the person leading the assessment to gather all relevant information. When a service user is accepted to the MHHTT service an admission notification should be faxed to their GP and up to date information requested, specifically currently prescribed medication. (Admission notification appendix 4) Refer to appendix 5 admission and discharge checklists 11 Early Discharge Planning The Mental Health Home Treatment Team will work closely with the inpatient wards to ensure that they identify service users who can continue their treatment at home. Mental Health Home Treatment Team will attend the Daily Review Meeting on each ward at least weekly. Assessment for patients on leave will include discussion with inpatient team to ensure acceptance [where appropriate] is conditional on early supported discharge. 12 Care Planning All service users receiving treatment at home will have a care plan that has been agreed collaboratively with them following a full health and social care assessment. Service users will always be offered a copy of their care plan. Mental Health Home Treatment Team staff will reference the care plan on each contact ensuring that care is delivered in line with what has been agreed with the service user. Care Plans will be reviewed by the key worker weekly. See appendix 6 for named worker role. 13 Home Based Treatment Home based treatment is the provision of specific interventions to resolve a deterioration in an individual s mental health as detailed below. The level of support will reflect the degree of risk and need identified through assessment and agreed in the planning phase with the service user, their carer and significant others. This will be detailed in the care plan which will be reviewed weekly by the named worker. There is no explicit time limit set for home treatment however evidence indicates that the majority of mental health crisis are addressed and resolved within a matter of weeks and often only days. Evidenced based interventions may include: 12

13 Assertive engagement with service users, families and carers. Intensive support (according to individual need). Practical assistance with daily activities. Education and help in understanding particular issues related to the mental health difficulty. Education and support for relatives and carer s, family work and/or carer involvement. Detailed assessments including standardized rating scales and assessment tools. Medicines management. Bio Psychosocial assessments and interventions. Relapse prevention work. Assessment of substance misuse Review Handovers of care from shift to shift will be led by the shift co-ordinator and will be centred around service users care plans. Handovers should be attended by the shift co-ordinator from the previous shift and staff taking over the care on the next shift. The handover on Monday should be attended by a member of the medical team to ensure that all new admissions are discussed by a multi disciplinary team. All service users in the red zone should be discussed daily in handover. Handovers take place at 9am 10am 1.30 pm 2pm 9pm 9.30pm All service users will have a weekly Multi disciplinary review of their care. The purpose of the weekly review is to Review the care plan to agree purpose of admission and review progress Ensure accurate prescribing and review of medication Make decisions on actions required to ensure timely discharge Identify and escalate barriers to discharge Identify safeguarding issues and agree actions This review will be recorded on Amigos 13

14 14 Zoning 14.1 Zoning definition All service users under the care of the Mental Health Home Treatment Team will be allocated to home treatment group (red or amber) or delayed discharge group (green). Refer to appendix Delayed discharges The definition of a delayed discharge is a service user who no longer requires home based treatment and could be discharged or transferred to appropriate follow up care. The reporting of delayed discharges will be through patient records on AMIGOS and the service dashboard. 15 Discharge Planning 15.1 Discharge from Trust Services Discharge planning from the Mental Health Home Treatment Team service will begin at the first contact with the service user and should involve colleagues who will work with the service user after discharge. If a service user is likely to need a new service this should be planned on admission or at the earliest point possible and a referral made at that time. The decision to discharge will be based on the resolution of the crisis plan/goals and a multidisciplinary discussion. This will be confirmed in the MDT daily handover meeting following consultation with the service user, carers and significant others including the care co-coordinator. The GP will receive a copy of the discharge notification which will be faxed on the day of discharge. (Appendix 8) The GP will receive a copy of the discharge letter within 10 calendar days. It is the responsibility of the named worker to complete the discharge letter which should be a copy of a risk follow up. The CPA plan must comply with Trust CPA standard documentation and remains the responsibility of the Care co-ordinator Transfer to In-patient Services This will only apply where the situation has deteriorated and the Mental Health Home Treatment Team will liaise to ensure that discharge is expedited (see gate-keeping form /early discharge). 16 Crisis Line The Mental Health Home Treatment Team provides a crisis line for existing service users. 14

15 The crisis line operates between 5pm and 9am on weekdays, and at weekends and on bank holidays. The crisis line is specifically for service users who are subject to the Care Programme Approach, are under Crisis Resolution and Home Treatment Teams and/or who are seen in outpatient clinics. The crisis line number is Crisis Line Guidance for staff - refer to Appendix 9 17 Interface with Services Mental Health Home Treatment Team will work effectively with Trust and non Trust services along the Acute Care Pathway. Trust Inpatient Teams through weekly attendance at ward level Daily Service User Reviews Area Teams through weekly attendance at allocation meetings GPs through clear communication regarding clinical care and discharge The Gateway Service PCMHT/ Psychology AMHPs Urgent Care Services (Bed Management, SAFIRE, MHLT) City Council Services eg. Children and Family Teams 18 Team Capacity 18.1 Capacity Management It will be the responsibility of the Team Manager (or their nominated deputy) and responsible medical staff to manage the overall workload of the individual teams. This will be informed through the effective use of zoning and daily demand data provided through the dashboard. It is expected that the Team Manager and medical staff will prioritise the care of service users in the red zone and review the resources available to meet demand. Demand, capacity and activity data will be available via the dashboard to assist with this process. Where the Team Manager and medical team have completed a thorough review of demand and resources and conclude that the team cannot safely manage their caseload this should be escalated to the Urgent Care Manager. 15

16 19 Medical Cover in Mental Health Home Treatment Team Each MHHTT will have a nominated Consultant Psychiatrist who will be medically responsible for the patients under the team. The Consultant will have dedicated time for direct clinical care sessions to support the team in MDT care planning meetings, clinical supervision and for the assessment and management of patients. The Consultant will have support from junior doctors and/ or a Nurse Consultant. The MHHTT will adopt a multidisciplinary approach and so it will not be necessary for each patient referred and accepted to the team to be medically reviewed. The need for a medical review will be discussed for each patient at regular care planning meetings. Whilst the MHHTT Consultant will be ultimately responsible for medical assessment and management of patients, in some exceptional instances patients may be reviewed by another Doctor that has medical responsibility for the patient such as the General Practitioner or the Area Team Psychiatrist. The frequency of medical reviews will be dictated by clinical need and reviewed in regular care planning meetings. Refer to appendix 9 for further guidance. 16

17 Flow chart to support guidance on delivery of gate- keeping by the MMHHT. Appendix 1 Referrer identifies that the need for an Inpatient admission is required Referral to MHHTT is made by the assessing clinician to the locality based MHHTT between 7am-9.30pm daily or out of these hours to the MHHTT 24hr cover on (0161) Face to Face gatekeeping assessment to be completed at the place of assessment with the exception of AMPH assessments where the individual is likely to be detained. In this instance the Gatekeeping can be conducted over the telephone with all revelent information. Out of working hours a face to face gatekeeping must take place in North, Central and South Manchester A&E departments. In exceptional circumstances where excessive delay in assessment would impact breach times can this be completed over the phone and the reason documented on AMIGOS. Need for admission The referrer escalates to the on call SpR with regard to the assessment. All assessments of treatment options including the MHHTT assessment and recommendations must be discussed with the SpR/Consultant. No need for admission No need for inpatient admission indicated therefore discharge from place of assessment to the indicated Service (MHHTT, Area Team, Primary care, etc). Discharge/transfer of care responsibility remains with the assessing clinician. Bed Management to be contacted by the MHHTT with all of the information from both inital assessing clinician and also the MHHTT assessment (Risk assessment and Gatekeeping assessment must be completed) If accepted for MHHTT input initial visit and contact telephone numbers to be given to the Service User and Carer. All other agencies involved with the individual's care must be informed of the assessment and arrangements by the assessing clinician. Management plan to be put in place including initial admission plan and purpose of admission by the decision maker/assessing clinician. Page 17 of 36

18 Appendix 2 Protocol for MHHTT assessment with reference to MHHTT referrals and requests for Inpatient admissions (Gate keeping) Objectives To ensure that all alternatives to admission have been considered at the earliest opportunity according to the principle of care in the least restrictive environment. To streamline the process of referral for admission and reduce the steps involved. To ensure all key clinical information is available prior to referral for admission. To ensure there is a clear and documented management plan available at the point of admission. To ensure senior medical staff and team managers are involved in the process of referral for admission. To ensure that all referrals for admission go through a MHHTT face to face gate keeping process which is recorded within the care record. Process 1. Agreement and documentation prior to referral The Trust is currently working on an electronic version of the full MHHTT referral information. In the short term the attached paper form can be used to capture additional referral details where it is not possible to record these directly onto Amigos. Where patients are already under the care of a CMHT (including Assertive Outreach and Early Intervention), the decision to refer for admission should be multi-disciplinary and involve the care coordinator and medical staff (or deputies). The team manager should also be kept up to date with progress. The patient s care record should be up to date and include: Relevant background history A risk follow up assessment (within last seven days) an updated record of recent events a management plan indicating the purpose of Referral or Admission. a social circumstances report (where assessed by an AMHP under the MH Act) 2. Accepting referrals All referrals for admission will initially be processed by the MHHTT Shift Co-ordinator at each site. As part of the initial referral process, MHHTT Shift Co-ordinator will discuss whether there are potential alternatives to admission, including MHHTT input. 18

19 In all cases this will involve MHHTT staff carrying out joint assessments with the existing care team or the on call doctor Liaison team worker. Only after this joint assessment should escalation to the SpR on call be made regarding locating an inpatient bed. The outcome of initial referral and/ or assessment will be formally documented on Amigos using the inpatient gate-keeping menu option. This is in the event focus list within the Notes section. Where patients are accepted for in-patient admission, the referral details will be passed from MHHTT to the bed management team without the referrer needing to make further calls. Responsibility for the interim care of the Service User remains with the referring service unless otherwise stated by the MHHTT. 3. Patients waiting for admission Where patients are already under an existing care team and are waiting for admission, the existing care team will remain responsible for their care until admission can be arranged, including ongoing liaison with the bed management team and co-ordination of any further Mental Health Act assessments. Where there are considerations of increased community support the MHHTT may be able to provide additional support where appropriate (e.g. through daily visits or telephone contact or support to carers) as part of a care plan overseen by the care co-ordinator (or deputy). 4. Responsibilities of bed management team The city wide bed management team will continue to co-ordinate an overview of available beds across all sites through regular contact with in-patient managers. Once a decision to admit the Service User to hospital has been confirmed by the MHHTT they will contact the Bed Management department to identify a bed whilst all of the outstanding documentation is being completed to ensure that there is not a delay in the location of an inpatient bed. 19

20 Admission Notification Appendix 3 Date: <Name of Department> <Address> <Address> <Address> <Post Code> PRIVATE AND CONFIDNETIAL To: Dr From: Tel: Fax: Tel: Fax: Subject: Admission Notification Dear Dr Re: DOB: NHS Number: I am wring to inform you that the above named person has been admitted to the Crisis Resolution and Home Treatment service on He/she presented with deterioration in mental health, the consultant in CRHT will be Dr Please could you fax us by return with details of this person s prescribed medication and summary of medical problems and blood test results. NB Whilst under CRHT your patient may be given medication for acute and/or emergency situation so please check with the team if you see the patient during their admission so you can consider and drug interactions. Wherever possible if prescribing can be safely delayed or a patient is stable on medication, CRHT medical staff will request that you take over the prescribing to ensure safe long term supply. We will aim to give 48 hours notice as a minimum where possible. For shared care drugs CRHT staff will arrange relevant blood tests and ECG. If patients prefer to have this done by their GP and the surgery is amenable to this your assistant in this matter will be greatly appreciated. If you require any further information, please do not hesitate to contact the Crisis Resolution and Home Treatment service on the above number. We will inform you when the client is to be discharged from our services and arrangements for future care. Yours sincerely 20

21 Admission and Discharge Checklist Appendix 4 MHHTT Admission and Discharge Standard Operating Procedures Date of admission Time of admission Patient Name District Number Within 24hrs Date/Time Within 24hrs Date/Time Within 24hrs Date/Time CRHT Practitioner Agree initial care plan Add service user details to team board Inform carers and care team of admission to CRHT Allocated named worker Ensure up to date service user details and client contact list Complete HoNOS and allocated cluster Provide service user details to team board Inform GP of admission to CRHT by fax Ensure any children service user has contact with are recorded and safeguarding issues considered Open episode on AMIGOS and ensure referral and assessment outcome recorded Team Administrator Ensure service user had correct medication and that any stockpiles are discussed/removed Obtain all relevant medical notes including those from other hospitals Obtain medication list and medical summary from GP Within 72hrs Date/Time Within 72hrs Date/Time Within 72hrs Date/Time Named Worker Face to face contact with service user Review and update care plan Medical Review either at Monday handover or MDT review Full MDT review and plan of care agreed Full MDT Review and plan of care agreed Review physical health care Rethink Check that service user is receiving medication as agreed Agree Estimated Discharge date and identify any barriers to discharge Agree Estimated Discharge date and identify any barriers to discharge Medical Team Multi Disciplinary Team Liaison with CC/Lead Professional and arrange joint visit Liaison with carers /family Agree and complete referral to Area Team/Psychology/PCMHT Agree and complete referral to Area Team/Psychology/PCMHT Set date for MDT review 21

22 Admission and Discharge Checklist - continued Appendix 4 MHHTT Admission and Discharge Standard Operating Procedures Date of admission Time of admission Patient Name District Number Within 24hrs Date/Time Within 24hrs Date/Time Within 24hrs Date/Time Named Worker Attend discharge Liaise with Update risk follow, CHORES meeting (MDT Meeting/handover) or nominate deputy Community Team and risk tick box Ensure transfer of care as per discharge plan Prescription completed Complete HoNoS and update cluster Complete medication part of discharge summary Medical Staff Complete discharge summary All investigation results checked Within 72hrs Date/Time Within 72hrs Date/Time Within 72hrs Date/Time Team Administrator Fax GP discharge notification Close episode on AMIGOS Send Exit Questionnaire 22

23 Appendix 5 Role of the Named Worker Every service user under the MHHTT will have a named worker who is responsible for overseeing and co-ordinating their care. Where the named worker is not available the Team Manager, Senior Practitioner or Shift Co-ordinator will cover this role. The role of the named worker To have face to face contact with their allocated service user within 72 hours of admission. Review and update care plan within 72 hours of admission and weekly thereafter. Complete any actions from MDT review. Act as Lead Investigator in any safeguarding investigation. Review physical health care Rethink. Check that Service user is receiving medication as agreed. Liaise with Care co-ordinator/ Lead Professional and arrange joint visit. Identify carers, establish effective communication with carers and offer carer s assessment. Where possible the named worker will develop and effective relationship with their service user. and carry out as many planned interventions as possible. 23

24 Appendix 6 Guidance on Zoning Red Zone High risk of self harm, harm to others or neglect according to Trust Risk Assessment Mental state unstable and service user experiencing distressing symptoms Needs daily contact from MHHTT Amber Zone Moderate risk of self harm, harm to others or neglect Mental state remains unstable but responding to treatment Requires between 2 and 4 visits weekly Green Zone Home treatment interventions completed and no longer requires home treatment team Service user can be discharged with appropriate follow on care 24

25 Appendix 7 Mental Health Home Treatment Team Manchester Mental Health and Social Care Trust Tel: Fax: FAX TRANSMISSION TO: Dr FAX: 0161 DATE: FROM: Dear Dr Re: Private & Confidential DOB: Address: I am writing to inform you that the above named client has been discharged from the Mental Health Home Treatment on This client has been under the care of the Mental Health Home Treatment since Please find enclosed a copy of the Risk Follow Up for this client. If you require any further information, please do not hesitate to contact the Mental Health Home Treatment Team on the above telephone number. Yours sincerely ADMINISTRATOR 25

26 Appendix 8a Staff Guidance for Working on the Crisis Line Guidance for the Crisis Line for all staff. As of the 16 th of December the Crisis Line has moved to the Urgent Care Group. As a result of this there is a responsibility to ensure that during the hours of operation that the Line is responded to. The hours of operation are as follows:- Normal working week Monday to Friday - 5pm-9am Saturday and Sundays 24hrs. Bank Holiday cover is 24hrs per day. At 9am on a normal working day the phone lines are transferred to a answer machine message by typing # A call to the Crisis Line should then be made on to ensure that the answer machine is in place. At 5pm the answer machine should be turned off by dialling ##9. A call to the Crisis Line should then be made on to ensure that the answer machine has been turned off. The Crisis Line is a fundamental role of the Trust for all Service Users under the care of the Trust. It is therefore imperative that the Crisis Line is always manned within the hours of operation. The provision of the Crisis Line staffing is that it must be covered by a qualified mental health professional (Nurse, Social Worker or Occupational Therapist). Within normal working hours any issues with the Crisis Line must be escalated to the Team Manager or the Urgent Care Manager immediately. Out of normal working hours escalation should be to the onsite bleep holder on bleep number This can then be escalated to the on call manager if the situation cannot be resolved. The Crisis Line is a Service Wide responsibility therefore cover arrangements are the joint responsibility of the Team Managers and Senior Practitioners. When taking a call the staff member should state ANSWERING THE CRISIS LINE Welcome to the crisis line my name is... can I take your name and DOB please Please hold the line whilst I check your records (check Amigos ) Caller is an existing trust service user, continue assessment and call to carry on ensuring that 1. CPA care plans are consulted including crisis plans 2. Discussions are documented on Amigos 3. Call log is completed for every call 26

27 4. Staff member following call should care co-ordinator and community RMO informing them of the call and to check amigos of the client accessing the crisis line. This should be cc d to include the CMHT team manager. 5. The above does not replace the faxes of notifications to the teams that are completed by the night staff and faxed by the early staff. ALL calls should adhere to the TRUST values and encompass the values of the 6c s at all times. If caller is not an existing trust service user the staff member must 1. Obtain name and GP details. 2. Complete brief assessment. 3. If risk is immediate contact emergency services. 4. If risk is not immediate caller should be signposted to GP and the new NHS helpline This call should be placed on the call log. 6. Staff should also inform GP if risk assessment deems necessary. 27

28 Appendix 8b Escalation process regarding short staffing for the Crisis Line 28

29 No member of staff attends to cover the Crisis Line. Within normal working hours Allocate member of staff immediately to cover the Service from existing resources. Outside normal Inform the Team Manager/Urgent Care Services Manger of the staffing issue Contact the Bleep holder for North Manchester to identify available staff to cover. Service resources to be considered CRHT staffing city wide. Urgent care staff from MHLT. Inpatient Services. If no staff available Authorize use of bank staffing where available or the use of Overtime or Agency staffing. Staff identified within Service resources without impact on functionality. Staff identified however with impact to Service resources. Escalation to Senior Manager on call. Datix must be completed with details of any visits or functions that have been cancelled due to pressures. Any significant risks must be discussed with the Senior Manager on call. 29

30 Mental Health Home Treatment Team Care Pathways Guidance for Team Appendix 9 Patients not under Community Area Teams (includes patients from Primary Care, Psychology and Outpatients) Presenting problems MHHTT Medical Input Prescribing Interventions Discharge / Written Communication Depression/ anxiety/ adjustments reactions New presentation of psychosis/ Bipolar illness Acutely unwell awaiting hospital admission No, unless clear indications To be discussed with team doctors before review booked Primary Care Assess risk, short term crisis work, signposting Yes, earliest possible MHHTT Medics Full assessment and management If needed MHHTT Medics Co-ordinate care until admission possible To primary care or referrer Brief non-medical discharge summary Early Intervention/ CMHT medical Discharge summery/ letter. To inpatient care Discharge summary not required. Diagnosis unclear Yes, best arrangements to be discussed with doctors before review booked. Physical and cognitive assessment if needed Primary Care where possible As needed to establish diagnosis Medical discharge summary/ letter Page 30 of 36

31 Patients under Community Area Team Presenting problems MHHTT Medical Input Prescribing Interventions Discharge / Written Communication To support early discharge from ward Crisis secondary to social stressors No, unless deterioration in mental state after ward discharge or need to review partially completed treatment plan Ward to agree discharge package MHHTT to ensure full list of medication available Prescribing from primary care Support care co-ordinator with discharge package Agree planned discharge date No Primary care Support care co-ordinator Agree planned support package Acute relapse Yes, earliest possible MHHTT Medics Full assessment and management Awaiting hospital admission Medical responsibility to remain with existing medical team but flexible approach required Flexible approach if needed Support care co-ordinator until admission arranged Agree planned interventions Care co-ordinator to oversee plan Clozapine initiation Yes, earliest possible MHHTT Medics Ensure clear medication management plan before admission including Investigations Pre-clozapine medication changes Clozapine registration with CMHT consultant To care co-ordinator Check outpatients follow up organised Discharge summary to be completed by inpatient team To care co-ordinator Brief non-medical discharge summary To care co-ordinator Check outpatient follow up organised Medical discharge summary/ letter To inpatient care Discharge summary not required To care co-ordinator Check outpatient follow up organised and clozapine prescribing transferred Medical discharge summary/ letter 31

32 Patients on/under a Community Area Team CTO Presenting problems MHHTT Medical Input Prescribing Interventions Discharge / Written Communication Patient on CTO having relapse which can be managed in community Patient on CTO requiring renewal, report for MHRT or attendance at MHRT RC responsibility remains with CMHT consultant. MHHTT consultant to provide short term input for review and decisions on treatment if needed. No RC responsibilities remain with CMHT Consultant GP or MHHTT Medics GP or MHHTT Medics Advice on prescribing and management whilst patient with MHHTT. Support care coordinator and CMHT RC. Advice on prescribing and management whilst patient with MHHTT. Support care coordinator and CMHT RC. To CMHT` To CMHT Patient on CTO requiring recall who has not has a significant period of involvement with MHHTT No recall responsibility lies with CMHT RC GP Support CMHT until admission arranged To inpatient bed Patient on CTO requiring recall who has had a significant period of involvement with MHHTT Flexible approach required Maybe appropriate for MHHTT Consultant to take lead. CMHT Consultant can request a transfer of RC responsibility to MHHTT Consultant with mutual agreement MHHTT Medics Support CMHT until admission arranged To inpatient bed 32

33 Appendix 10 Role of the Shift Co-ordinator At the start of each day shift, one qualified member of staff will be allocated as shift co-coordinator. This is identified as a green dot on the rota. The role of the shift co-coordinator is as follows: To ensure all staff are present at the start of the shift To screen all telephone messages To discuss all referrals and arrange assessments To ensure the handover meeting is held promptly and that it is centred on current care plans To allocate all clients to appropriate members of staff as indicated on the contact sheets To ensure that visits are spread evenly throughout the day To ensure that contacts have a meaningful purpose and are related to the care plan To ensure resources are allocated according to demand To consult the team diary and ensure all tasks are allocated and completed To ensure that all staff are safe and accounted for at the end of a shift Page 33 of 36

34 Appendix 11 Contact Details Contact details 09.00hrs to hrs North Locality Office contact number Mobile Central Locality Office contact number Mobile South Locality Office contact number Mobile Between and there is a city wide 24hr MENTAL HEALTH HOME TREATMENT Manchester and the contact details for this service are: TEAM service which operates out of North Night time MENTAL HEALTH HOME TREATMENT TEAM (0161) All new referral to the Trust are dealt with in the Gateway service. Their contact number is Page 34 of 36

35 Critical to Quality Measures Appendix 12 Critical to Quality Characteristic Currently measured by Additional measures for development Linked to service goal Quality care - Workers with the right skills - Care delivered in the right place - Better access to a range of therapies and interventions - Service user needs at the heart of the service - Services which flex to meet the needs of the service user - Quality is measured from the service user's perspective - Service achieves the standards as set out in the HTAS pilot [CCQI] Safe Care - People work in systems which make it easier to put safe care first - Vulnerable individuals who may or may not be the service user s rights are safeguarded - Meets our legal and regulatory requirements Efficient care -Access to services is timely, flexible and responsive according to need and equitable across the city -Seamless care more joined up -Improves flow through services involving closer partnership working -Discharge focused -Best use of resources available -Achieves financial objectives [CIP] -Right people, right skills -Services which make best use of -Service user exit questionnaire -Complaints information [not reported specific to MENTAL HEALTH HOME TREATMENT TEAM -Cluster information [no collection of clusters] - Number of incidents [SUIs] and trend analysis - Service user exit questionnaire - Complaints information - Numbers of safeguarding referrals and investigations and outcomes - medicines management audit [individual to team] -Length of stay [average only] -Activity information admissions and discharges [including early supported discharge] - Accepted and declined referrals -Time from referral to assessment -Time from assessment to treatment [does not reflect where SU not available] -Therapy outcome measures [informed by HTAS] -Service user/carer reported outcomes measures [informed by service users engagement] - Local audit of outcome measures - numbers of service users open to teams in each cluster group - complaints information for MENTAL HEALTH HOME TREATMENT TEAM service -Clinical audits relating to safety [city wide] -Service user and carer workshops - Medication management audits [city wide] -Capacity and demand information [use of SPC] - Process maps- service interfaces -Audit of referral process and outcomes including Gatekeeping [Gateway oversight group] -destination on discharge - LOS target and & achieved - Expected discharge date - delayed discharges - all activity details including non face to face activity G1 G3 G5 G5 G1 G3 G5 G4 G6 Page 35 of 36

36 workforce skills and match these to the needs of the service user -Flexibility on the management of the workforce to meet variation on demand -Model of care that meets the requirements of payment by results -Model of care that matches capacity to demand and responds to expected changes Effective care -Meets NICE and other clinical guidance (national and local) - Demonstrates positive outcomes for service users - Recovery focused - Service user needs define the pathway or package of care to be delivered -Doing the right thing at the right time -Increase the amount of time staff spend doing the things that matter to service users -Reduce the burden of bureaucracy Information systems that support and enhance the delivery of care - Cluster/HONOS information -Service user complaints -Exit questionnaire -Financial information -Workforce information -Activity information for individual staff and staff groups [only captures face to face activity] - HoNoS/Cluster -Service User Questionnaire -Cluster information - Activity by team - re referral 14 days and 3 months -Therapy and service user outcome measures -Re referral rates within 72 hours and within 7 days - clinical audit programme G2 G1 G4 G5 G2 MENTAL HEALTH HOME TREATMENT TEAM TEAM Service Goals GOAL 1: We provide excellent quality and effective care based on evidence based practice that promotes recovery, inclusion and choice. GOAL2: We promote and support the provision of care based in the least restrictive environment. GOAL 3: We involve people in planning their care and in improving services. GOAL 4: We provide efficient services supporting a culture of learning and innovation. GOAL 5: We value and develop our workforce. GOAL 6: We provide a multidisciplinary approach, working with all stakeholders to ensure integrated working along the care pathway. Page 36 of 36