Mental Health Care Pathway (prototype)

Mental Health Care Pathway (prototype)
Self-help & Caring Psychological Therapy Services (IAPT) Coping with daily living problems Coping with daily living problems Primary care Care pathways services Exit from Mental health services Service Pathways Hants Oxon General hospital services Other agencies Commissioning for mental health i

Mental Health Care Pathway
Mental health Services Children Adults Older people Learning disability Diagnoses Search Help Self-help & Caring for mental health problems How do I contact Psychological Therapy Services (IAPT)? Coping with daily living problems Primary care Mental health Exit from services Care pathways for mental health problems MENTAL HEALTH MENTAL HEALTH General hospital Services and Mental health How do I find mental health Services? Service pathways through mental health services Other agencies which work with mental health services Please insert UK postcode for locaised information Comments: Web-links that are provided as part of this programme are ones which we hope you will find useful but their inclusion should not imply that the relevant web content is endorsed by NHS South Central or other NHS organisations supporting the development of this programme. Permission to use pathways developed by South London and Maudsley FT (SLAM) is awaited. Developed by David Kingdon for NHS South Central with contributions from many individuals for which grateful thanks (comments welcomed to )

What is a mental health problem?
There is often confusion about what is a mental health problem, mental disorder or mental illness. A disorder (or problem) could be described as any condition that causes distress or disability (physical or mental). However whether someone presents, or rarely is presented, for help or requires reduction in their responsibilities e.g. time off work, varies greatly from person to person and in relation to the cause of the disorder. Society has standards and mechanisms for deciding whether someone is ill or not – usually relying on the General Practitioner to make that decision. For example, depression is a disorder but need not be an illness. It can be very severe, e.g. after a bereavement, but the individual may request very limited support or intervention. On the other hand, relatively ‘mild’ depression may present and treatment may be appropriate in someone with limited coping abilities and little social support. It may be agreed that they are ill and psychological intervention, for example, be reasonable. Similarly for physical conditions, a bruise might be described as a disorder but not an illness – though it could become one if it causes swelling or severe discomfort. Web-links that are provided as part of this programme are ones which we hope you will find useful but their inclusion should not imply that the relevant web content is endorsed by NHS South Central or other NHS organisations supporting the development of this programme. Comments: - specific service websites will often have addresses for comments, if not these can be made to - comments on the website can be made to Developed by David Kingdon for NHS South Central with contributions from many individuals for which grateful thanks

Getting access to mental health services
Emergency Where there is immediate risk to life or serious physical injury, the emergency services should be contacted using 999. Examples would be where someone has taken or seriously threatening to take an overdose of medication or made another suicidal action especially where they are showing signs of its effects, e.g. slurring or sleepiness (ask for ambulance); or where someone is threatening aggression, holding a weapon or committing or about to commit an assault (ask for police). Urgent Where someone is very distressed or may be talking about harming themselves or someone else, immediate attention may be necessary If they are currently under the care of mental health services, contact should be made with those services (local services can be located through NHS Choices ) or their general practitioner or NHS Direct. If not under the care of services, contact should be through the person’s general practitioner (or NHS Direct ) or if the person is in a public place (not their own home), the police can be contacted and may intervene. A relative of a patient can ask local mental health services for a Mental Health Act assessment by a psychiatrist and approved mental health practitioner Routine Most services accept referrals from General Practitioners and so these referrals usually occur after discussion about mental health care needs at an appointment with a GP (local services can be located through NHS Choices ). Some services accept self-referral (e.g. Psychological Therapy Services , Drugs & Alcohol or Early Intervention in Psychosis teams) Some people are referred from the Courts, Prisons or by the Police.

Contact with services General hospital
Some people present to Emergency Departments with mental health problems, e.g. after self-harming or accidents. They may also present to specialist out-patient clinics or as in-patients and require treatment, in collaboration with their family doctor and, sometimes, referral to specialist mental health services. Criminal Justice Service (Police, Probation, Courts or Prisons) The police may be called and can act where mental health issues arise especially where there is concern about harm to others or self in public (and sometimes private) places. Courts and prisons may also refer to mental health services including through specialised liaison services.

Primary Care (including general practitioner or family doctor services)
GPs provide front-line mental health care as part of their service to their patients. Most people with mental health problems will therefore never require help from specialist mental health or psychological treatment services. However where it is necessary, such referrals are possible. Quality & Outcomes Framework

Primary Care NO ACTION ASSESSMENT EPISODE INTERVENTION COMPLETION
Explanation of symptoms or sign-posting may be sufficient. Consider watchful waiting for emotional difficulties. NO ACTION Holistic assessment including both mental and physical state. Consider carer perspective Consider diagnosis especially early intervention in psychosis Consider relapse prevention and sign-posting INTERVENTION ASSESSMENT EPISODE COMPLETION Watchful waiting & self-help resources Where appropriate, agree shared care with mental health services – especially where non-cooperation is issue. Medication or brief psychological intervention – see care pathways &/or: Resource: The management of patients with physical and psychological problems in primary care: a practical guide REFERRAL Access local psychological therapy services (IAPT) or mental health services If referral refused by patient, consider discussion with local CMHT or early intervention team

Underpinning values 10 Essential Shared Capabilities.
Working in Partnership. Respecting Diversity. Practising Ethically. Challenging Inequality. Promoting Recovery. Identifying People’s Needs and Strengths. Providing Service User Centred Care. Making a Difference. Promoting Safety and Positive Risk Management. Personal Development and Learning.

Partner Agencies Statutory: Police Councils General Hospitals
Hampshire Thames Valley Councils Oxfordshire Southampton General Hospitals Southampton University Hospital Trust Royal Hampshire County Hospital Basingstoke Hospital Radcliffe Voluntary: National AgeUK Alcohol Concern Alzheimers society Centre for Mental Health MENCAP Mental Health Foundation MIND RETHINK Voluntary Services YOUNG MINDS Local MIND (Oxon Solent) Restore (Oxon) No Limits (Soton) Voluntary Services (Oxon Soton) Housing & Employment City limits (Soton) Shelter

Assistance with coping with life’s problems
Physical health Housing issues Money Memory problems Patient rated outcome measure Drugs & Alcohol Patient rated outcome measure Work Caring for others Relationships General practical advice Cultural support Education Leisure activities Mental distress Spiritual issues DropBy For further help: Mental Health Care Pathways The Big White Wall The support network

Housing issues National organisations
Shelter Crisis Homeless Link Gateways to homelessness services: Homeless Healthcare Services (Soton) Street Homeless Prevention Team (Soton) ‘No-One Left Out: Communities Ending Rough Sleeping’ Mental health and homelessness good practice guide Asylum seekers

GENERAL HOSPITAL SERVICES
Ambulance Services Emergency Department Access to mental health services Management of Deliberate Self-Harm Perinatal (mother & baby) mental health care Psychological medicine (General hospital liaison) Mental Health Act , Mental Capacity & Deprivation of liberty (DOLS) guidance Specific conditions Dementia & Delirium Physically unexplained symptoms Other mental health conditions Local Hospitals

Care pathways These are ways of describing the care needed for specific mental health conditions. Broadly these are: Emotional difficulties, usually presenting with distress Psychosis, where there is some confusion or disagreement with others about what is really happening Memory difficulties, where these may be from changes to the brain Developmental difficulties where development has been held back in learning disability or is a problem, e.g. with behaviour Substance misuse - drug or alcohol problems Much fuller information is given in books & leaflets or diagnostic systems.

Care pathways Values Memory Psychosis Difficulties
R&D OASIS Memory Difficulties R&D Patient rated outcome measure Global outcome measure Patient rated outcome measure Global outcome measure Emotional difficulties Developmental difficulties Substance misuse Values Self-diagnosis Payment-by-Results R&D – studies actively recruiting

Care pathways Values i Memory Psychosis difficulties
R&D OASIS Memory difficulties R&D Anxiety/depression & related conditions Learning disability Patient rated outcome measure Global outcome measure Patient rated outcome measure Global outcome measure Eating disorders Emotional difficulties Developmental difficulties Bipolar disorder R&D OASIS ‘Rapid cycling’ Borderline Personality Disorder Other: Incl. Autism (ASD), ADHD, Conduct disorder. Substance misuse Values Drugs Alcohol Payment-by-Results i R&D – studies actively recruiting

Care Pathways – Anxiety/depression & related conditions
Review NICE priorities Depression NICE guideline Review NICE priorities Specific outcome measures Anxiety NICE guideline Anxiety/ depression etc pathway Anxiety/ depression, etc (diagnosis) Somatising ‘physically unexplained’ IAPT Guidance Specific outcome measures Review NICE priorities NICE guideline PTSD OCD & Body Dysmorphic Disorder’ Review NICE priorities NICE guideline Self-help & caring

Care Pathway – Anxiety/Depression & related conditions
Exit from services Specific outcome measure (CORE & IAPT) Specialist mood disorder service Referral to Psychological Therapy Services (IAPT) Community pathway Specific outcome measure Medication review Review NICE priorities Assessment & risk management Requires Mental Health Service intervention Confirm diagnosis Assertive outreach/ Recovery team Requires maintenance support Acute care pathway Psychol -ogical review Not require Mental Health Service intervention CMHT Self-help & caring NICE guidelineS PbR clusters Asylum seekers

Values SERVICE PATHWAYS Patient rated outcome measure
Hampshire Values Learning disability services Information Transitional protocols Patient rated outcome measure Global outcome measures Child & Adolescent Services Patient rated outcome measure Global outcome measures (electronic record) Transitional protocol Acute care Community Recovery Adult services Service pathways Liaison Perinatal Early Intervention Transitional protocol QUALITY Essentials CQUIN Standards & Survey National Patient Safety Agency Acute care Community Older people’s services Liaison Memory assessment Forensic services Substance misuse services Finance Training HR

MENTAL HEALTH SERVICE PATHWAYS
Values Learning disability services Information Transitional protocols Patient rated outcome measure Global outcome measures Child & Adolescent Services Patient rated outcome measure Global outcome measures (electronic record) Transitional protocol Acute care Community Recovery Adult services Service pathways Liaison Perinatal Transitional protocol QUALITY Essentials CQUIN Standards & Survey National Patient Safety Agency Acute care Community Older people’s services Liaison Memory assessment Forensic services Training Substance misuse services

MENTAL HEALTH SERVICE PATHWAYS
Values Learning disability services Information Patient rated outcome measure Global outcome measures Child & Adolescent Services Patient rated outcome measure Global outcome measures (electronic record) Transitional protocol Acute care Community Recovery Adult services Service pathways Liaison Perinatal QUALITY Essentials CQUIN Standards & Survey National Patient Safety Agency Acute care Community Older people’s services Liaison Memory assessment Forensic services Training Policies Substance misuse services

Care Pathways – Memory Difficulties
Global outcome measure – HoNOS 65+ Review priorities Early Memory Difficulties Memory assessment pathway Review priorities Mental health pathway Moderate need pathway Review priorities Memory DifficultiesR&D (diagnosis) Global outcome measure – HoNOS 65+ High need pathway Review priorities High physical or engagement need pathway Review priorities Self-help & caring

Quality & Outcomes Framework (mental health)
Check your local surgery results Resources RCGP forum Early intervention in psychosis

DIALOG Recovery Star How satisfied are you with your mental health?
How satisfied are you with your physical health? How satisfied are you with your job situation? How satisfied are you with your accommodation? How satisfied are you with your leisure activities? How satisfied are you with your friendships? How satisfied are you with your partner/family? How satisfied are you with your personal safety? How satisfied are you with your medication? How satisfied are you with the practical help you receive? How satisfied are you with consultations with mental health professionals? Couldn’t be worse Displeased Mostly dissatisfied Mixed Mostly satisfied Pleased Couldn’t be better No response Additional help required? Yes/No ……………………………………. Recovery Star

Self-help SUBSTANCE MISUSE GENERAL Books INFO Talk-to-Frank (drugs)
Drinkaware Alcoholics Anonymous Alcohol Concern NHS Choices Royal College of Psychiatrists GENERAL INFO Books NHS Choices MIND MENCAP RETHINK Choice and Medication Royal College of Psychiatrists EMOTIONAL DIFFICULTIES Books NHS Choices Computerised CBT Royal College of Psychiatrists PSYCHOSIS Books Hearing Voices Network RETHINK MIND NHS Choices Royal College of Psychiatrists MEMORY DIFFICULTIES Books Dementia gateway NHS Choices Royal College of Psychiatrists

Carers Books Al-Anon (alcohol carers support) Alcohol Concern
Caring (finance, etc) Care choices Choice and Medication Confidentiality and sharing information Dementia gateway Mental health care (psychosis) Mental health first aid NHS Carers Direct Princess Royal Trust for Carers RETHINK Royal College of Psychiatrists

Memory difficulties Emotional difficulties Psychosis Substance misuse Developmental difficulties

Developed by SLAM

Acute care pathway DISCHARGE REFERRAL TREATMENT Acute Pathway
CRHT INPATIENT PICU INITIATING CARE TREATMENT Acute Pathway Quality & Performance Dashboard

Acute care pathway REFERRAL
Single point of access & rapid response by Crisis Resolution Home Treatment Team (CRHT) Assessment involving SU, carer and relevant others (risk issues including safeguarding children and adults) Consider Mental Health Act , Capacity & Deprivation of liberty (DOLS) Assess at home whenever possible REFERRAL OUTCOME Admission to hospital CRHT care Refer to CMHT or maintenance by current team Engage other services/signpost Discharge to GP PICU Inpatient CRHT BUILD ON INITIAL ASSESSMENT (INCLUDING RISK) AND BEGIN RECOVERY AND STRENGTHS FOCUSSED THERAPEUTIC APPROACH WITH SERVICE USER INVOLVEMENT

Acute care pathway INITIATING CARE
Communicate with referrer, home acute unit & GP Assertive Engagement Gate Keeping Engage Carer /carer support worker Maintain contact with care co-ordinators (community pathway) Obtain case notes or electronic equivalent Confirm admission objectives Commence discharge planning with projected discharge date, housing needs & care Plan HoNOS on admission Consider input required from social, advocacy and other agencies Complete admission checklist ‘Meet and Greet’ establish consent to admission Immediate risk assessment/support level/ward environment Orientation to ward Identify physical needs (e.g. check Body mass index [BMI]) If detained read rights

Acute care pathway TREATMENT
Side effect monitoring, improve concordance & Wellness Recovery Action Plan (WRAP) Supplement assessment which may include the intervention of other professionals, e.g. forensic Commence interventions to include psychological in broad sense (include CBT, interventions to enhance resilience, crisis planning, relapse prevention, problem-solving, anxiety management) Regular MDT review Consider input required from social care, advocacy and other agencies Senior/Professionals’ review Ward round/Consultant review Consider involvement of & early discharge to CRHT Manage physical health care needs TREATMENT Assertive engagement, intensive support Time limited intervention, medication review if needed. Manage self-harm & hostility (include incident & complaint reporting) Practical help with basics of daily living and crisis plan Use of Crisis beds when available Engage Carer/care support worker Maintain contact with care coordinator (community pathway) Investigations Formulate problems/diagnosis on bio-psycho-social model Consider medication and other interventions including ECT

Acute care pathway DISCHARGE Engage Carer/care support worker
Agree discharge date Prepare for discharge/transfer Consider active involvement of CRHT & input required from social care, work and other agencies CPA joint review with care coordinator/community consultant including relapse prevention plan Use of step-down/Crisis beds when available Consider trial leave Complete discharge checklist HoNOS on discharge Agree follow-up: Outpatient, CRHT & Care Co-ordinator (<48hr [high suicide risk] or <7-day) Discharge summary (within 2 weeks)

Community pathway DISCHARGE REFERRAL TREATMENT Community Pathway
CMHT INITIATING CARE TREATMENT Community Pathway Quality & Performance Dashboard

Community pathway REFERRAL Provide single point of access
Rapid response proportional to urgency Assessment involving patient, carer and relevant others (also risk issues including safeguarding children and adults) REFERRAL OUTCOMES Brief intervention (include Discharge Liaison Team involvement). Enter acute care pathway Refer to specialist team (Early Intervention, Substance Use, Assertive, Rehabilitation) Accept referral & allocate care co-ordinator &/or to outpatient care; engage other services/signpost Discharge to GP CMHT BUILD ON INITIAL ASSESSMENT (INCLUDING RISK) HoNOS AT INITIAL CONTACT. BEGIN RECOVERY AND STRENGTHS FOCUSSED THERAPEUTIC APPROACH WITH SERVICE USER INVOLVEMENT

Community Pathway Arrange appointment Assertive Engagement
INITIATING CARE Arrange appointment Assertive Engagement Engage Carer /carer support worker Develop treatment objectives & timescale Commence Care Planning Consider input required from social care, work, advocacy, housing and other care agencies Identify physical needs (e.g. check Body mass index [BMI]) Consider need for psychiatric review Mental Health Act (on Section 17 leave, 37(41) or Community Treatment Order) Consider self-directed support (personalisation) & Wellness Recovery Action Plan (WRAP) Communicate with referrer & GP

Community pathway TREATMENT
Formulate problems/diagnosis on bio-psycho-social model Time limited intervention, medication review if needed. Practical help with basics of daily living and crisis plan Consider need for psychiatric review & review medication needs Consider fitness to drive or use machinery Supplement assessment which may include the intervention of other professionals, e.g. psychologist, occupational therapist Reconsider self-directed support (personalisation) Commence interventions to include psychological in broad sense (include CBT, DBT, interventions to include resilience, crisis planning, relapse prevention, problem solving, stress management) CPA review (repeat HoNOS) Report & manage any complaints Consider input required from social care, work and other agencies Physical needs reassessment Continue to assess risk, MHA & need for acute pathway Side-effect monitoring, improve concordance Caseload & clinical supervision Review NICE guideline for condition Regular communication with GP, accommodation provider & carer

Community pathway DISCHARGE/TRANSFER
Consider whether criteria for recovery pathway met Engage Carer/carer support worker Consider input required from social care and other agencies Agree discharge date Prepare for discharge/transfer CPA review with relapse prevention plan HoNOS on discharge Communicate with GP

OPMH Community pathway
DISCHARGE REFERRAL CMHT INITIATING CARE TREATMENT Community Pathway Quality & Performance Dashboard DropBy

OPMH Community pathway Assessment
REFERRAL Provide single point of access Rapid response proportional to urgency Assessment involving patient, carer and relevant others (also risk issue including safeguarding children ,adults) RISK ASSESSMENT, HoNOS REFERRAL OUTCOMES Brief intervention (include Liaison Team involvement). Accept referral & allocate care co-ordinator Engage other services/signpost Enter inpatient pathway Discharge to GP CMHT Multidisciplinary review. Initiate other assessments- psychology, occupational therapy, nursing ,medical Review of Risk. Initiate care planning. Liaise with partner organisations- Adult Services, Community Healthcare.

OPMH Community Pathway
INITIATING CARE Arrange appointment, either at home or community base Engage Carer /carer support worker Identify further assessments needed- psychological, cognitive assessment, occupational therapy, physical health assessment. Consider need for psychiatric review including Mental Health Act assessment . Identify need for investigations, blood test or scanning. Consider referral to Adult Services, care agencies, advocacy, work Develop treatment objectives & timescale Commence Care Planning Consider self-directed support (personalisation) Communicate with referrer & GP

TREATMENT Formulate problems/diagnosis. Identify interventions and time frame. (Care Planning) Practical help with basics of daily living and crisis plan Consider psychiatric review & review medication Consider fitness to drive or use machinery Reconsider self-directed support (personalisation) Psychological interventions including cognitive work, CBT, crisis planning, relapse prevention, problem solving, stress management Occupational interventions to support independent living Consider input required from adult services, work and other agencies CPA review (repeat HoNOS) Physical needs reassessment Ongoing Risk Assessment Consider MHA & need for acute pathway Side effect monitoring, improve concordance Caseload & clinical supervision Report & manage any complaints Review NICE guideline for condition Regular communication with GP, accommodation provider & carer

DISCHARGE/TRANSFER Consider whether criteria for discharge are met Engage Carer/carer support worker Consider input required from Adult Services and other agencies Agree discharge date Prepare for discharge/transfer CPA review with relapse prevention plan HoNOS on discharge Communicate with GP

Eating Disorder Service Pathway
DISCHARGE Engage Carer/care support worker Agree discharge date Prepare for discharge/transfer Consider active involvement of CRHT & input required from social care, work and other agencies CPA joint review with care coordinator/community consultant including relapse prevention plan HoNOS on discharge Agree follow-up: Outpatient, CRHT & Care Co-ordinator Discharge summary (within 2 weeks) INTERVENTIONS Outpatient, day care (12 weeks) or Inpatient (Acute Care Pathway or General Hospital) 1st session measures: CPA review Physical monitor with relevant investigations (coordinated with GP) Guided self-help: 4 month – 6 direct contacts Nutritional advice Group work Medication review Psychological interventions: Family therapy, Group work, DBT modified, individual & group; Inter-personal therapy – 24 sessions: CBT – 20 sessions CAT – 16, 24, or 32 sessions: Measure CORE-10 REFERRAL Waiting list INTERVENTIONS DISCHARGE REVIEW NICE PRIORITIES REFERRAL Screening: Assess comorbidities jointly with CMHT Inform referrer Comprehensive Assessment involving service user, carer and relevant others (include mental health, social functioning & risk issues - including physical); relevant measures. Consider Mental Health Act & Deprivation of liberty (DOLS) Team discussion; choose treatment options; discuss & agree with service user REFERRAL OUTCOME Taken onto waiting list by Eating disorder service Refer to CMHT or maintenance by current team Engage other services/signpost Discharge to GP

Early Intervention in Psychosis Service Pathway
First presentation for assessment of psychosis (aged 14-35) 24 hour access Provide service & self-help materials Complete specific outcome measures: PANSS, GAF, HADS, Drake. Follow COMMUNITY & PSYCHOSIS PATHWAYS Focus on psychological and family work. Carer support Assertive care coordination Medication management Outreach to schools, colleges, youth organisations, GPs, etc Urgent ACUTE CARE PATHWAY REFERRAL TAKEN ON BY EIT (up to 36 months) REFERRAL OUTCOME ASSESSMENT BY EIT (up to 6 months) Non-Urgent (within 7 days) EIP ASSESSMENT NO PSYCHOSIS Early intervention Sites [IRIS, EPPIC] Refer on to CMHT or other mental health service or back to GP or referrer

General Hospital Liaison Service Pathway
REFERRALS FROM WARDS AND THE EMERGENCY DEPARTMENT Accepted from medical staff responsible for the patient between: 09:00 – 17:00hrs, Monday to Friday for 18 – 65 year olds If the referral is received after 16:00:- There will be provision of initial advice and assessment if there is a clinical crisis Referrals from the Emergency Department to the Home Treatment Service if the patient is expected to become medically fit for discharge later in the evening Assess in working hours if there is no need for urgent specialist mental health input. Advice will be provided to General Hospital staff to guide management if the patient deteriorates REFERRALS TO PSYCHOLOGICAL MEDICINE OUT-PATIENT CLINIC Referrals for routine out-patient assessment can be accepted for patients aged years requiring ongoing out-patient or in-patient follow up from General Hospital. Referrals to the out-patient clinic should be made by letter from the Consultant (or Specialty trainee after discussion with the consultant) responsible for the patient detailing reasons for referral and summary of physical health issues. It is helpful to attach recent clinic letters (the service does not have access to eDOCs). If the referral cannot be seen due to another service being thought more appropriate or lack of capacity in the service then this decision will be communicated by letter to the referrer and GP. Patients requiring urgent out-patient assessment (for example due to active suicidal ideas or acute psychotic symptoms) cannot be seen by the service. This initial mental health assessment needs to be undertaken by the GP. Advice for General Hospital staff regarding patients already receiving treatment from another mental health should be sought from that mental health team. If it is thought that a specialist assessment from the Psychological Medicine team would be helpful due to the complexity of interaction between physical and mental health issues then the specific reasons for referral to the service and the details of the existing mental health team need to be included in the referral letter. The letter should also be copied to the community mental health team. The following problems are suitable for referral: Prolonged or severe adjustment disorder impairing physical, occupational or social functioning; Moderate depression or anxiety disorder impairing functioning or self care of the physical health condition; Somatoform and dissociative disorders resulting in frequent admissions or attendance to the Emergency Department or out-patients; Psychological issues impacting on self care e.g. poor adherence; Psychological problems affecting physical health or health care utilisation where the patient does not yet accept referral to psychological therapy services but agrees to attend the Psychological Medicine clinic. The following problems should be managed via the GP (who may refer to community mental health services); Urgent referrals – e.g. strong suicidal ideas, active psychosis; Mental health problems in patients who will not be receiving ongoing care from General Hospital; Mild depression or anxiety; Depression or anxiety disorders unrelated to the physical health condition; Substance misuse; Somatoform or other medically unexplained symptoms not resulting in frequent presentation to General Hospital REFERRAL PROCESS (in-patient & outpatient) TEAM RESPONSE REFERRAL ROUTE REFERRAL CRITERIA REFERRALS OUTSIDE THE WORKING HOURS OF THE TEAM Only patients requiring crisis/urgent clinical advice or assessment by a mental health specialist after initial assessment and attempts at management by the responsible medical team will be accepted outside working hours. It is expected that the referral will be made by a doctor of at least middle grade seniority. Referrals from General Hospital wards: The referring doctor should contact the the duty psychiatric service (nurse bleep holder in Antelope House (bleep 1504)). The call will be passed to the senior psychiatrist on call who will provide telephone advice and, if necessary, come to see the patient. Referrals from the Emergency Department: The referring doctor should contact the Crisis Resolution/Home Treatment Service Crisis referrals from General Hospital out-patient clinics or occupational health Mental health assessment should be arranged by the patient’s GP or rarely Emergency Department, who can then access community mental health resources if required. REFERRAL CRITERIA All patients admitted after self harm (overdose, self laceration, attempted hanging, jumping from a height, gunshot wound): Organic psychosis: Schizophrenia and other functional psychosis where the disorder is affecting management in General Hospital: Depression or anxiety interfering with physical healthcare or recovery: Adjustment reactions interfering with physical healthcare or recovery: Eating disorders leading to admission: Behavioural disturbance if mental health issues are thought relevant: Somatoform, dissociative and fictitious disorders if there is frequent attendance or co-morbid physical disease requiring ongoing in-patient or out-patient care from General Hospital: Diagnostic dilemmas where mental disorder is a possibility: Patients where psychological factors are thought to be affecting communication or other aspects of care by General Hospital staff: Capacity advice if mental health issues are thought relevant or the decision is complex and the General Hospital consultant wants further advice after their own assessment: Alcohol and other substance misuse if other mental health problems are present (e.g. severe depression remaining after detoxification, hallucinations remaining after detoxification) The following types of problems should not be referred but be highlighted to the GP for management after discharge: Mild depression or anxiety: Pre-existing mental illness not affecting care in General Hospital: Alcohol and other substance misuse

General Hospital Liaison Service Pathway
TEAM RESPONSE TO REFERRALS On receipt of referral admin staff will check if the patient is already known to local mental health services, obtain any recent mental health correspondence and notify clinical staff of the referral. If the clinician receiving a referral requires more clinical information to prioritise response then they will contact the referrer or other mental health teams as required. If the patient will not be seen the same day then a clinician will telephone the referrer to check that the patient is settled and, if appropriate, give advice regarding how to contact out of hours services should the clinical situation deteriorate. If the referrer is unavailable then the clinician will liaise with ward nursing staff. If referrers telephone the team for advice or to discuss a referral admin staff are expected to take down the following information: Name of patient; Hospital and NHS numbers; Age; Name of the referrer and bleep or other contact number; Ward location; Is it an acute crisis needing immediate discussion with a practitioner? Supervision policy. REFERRAL ROUTE Referrals should be made by faxed referral form with letter (unless assessment after admission for self harm) which should always include:-reason for referral / question asked of the Psychological Medicine team; mental state assessment and other reasons leading to suspicion of mental illness or psychological problems impairing management within General Hospital: reason for treatment in General Hospital: a summary of physical management and past admissions: results of recent investigations If it is unclear whether a patient needs to be referred, or the referrer wants to discuss the referral for other reasons, then they should telephone the department. If there is no clinician present in the team base at the time, admin staff will record the name and contact details of the referrer and arrange for a clinician to ring back. In crisis situations, the referral can be made solely by telephone discussion with a clinician in the team Prioritisation of referrals: Initially on the basis of clinical urgency and risk and secondly on location in General Hospital in order: Emergency Department, Acute Medical Unit, other wards. The team aims to respond within the following time frame: Crisis: 1 hour (usually within 30 minutes): Urgent: same day (if the referral is received late in the day then response is likely to be by telephone advice that day and direct assessment the next day): Routine: 3 days (usually within 1 working day) REFERRAL PROCESS MENTAL HEALTH INTERVENTION REFERRAL ROUTE REFERRAL CRITERIA TRANSFER TO GENERAL HOSPITAL FROM A MENTAL HEALTH IN-PATIENT UNIT HPFT Clinical Policy 57 & SUHT details expectations and responsibilities for HPFT and General Hospital staff for patients transferred to General Hospital for physical healthcare from a mental health in-patient unit. If a patient needs constant (1:1) observation due to their mental health needs in General Hospital then the responsibility for providing this is local mental health trust if the patient was transferred from a MHT bed. Responsibility lies with General Hospital if the patient was admitted from the community or another acute hospital. Mental health act issues. COMMUNICATION AND DOCUMENTATION Team members have a responsibility to follow team practices regarding documentation. Document the clinical assessment, risk assessment, formulation, and management plan in the General Hospital notes and retain a photocopy for DPM notes; Discuss with DPM team as necessary; Recording of risk and clinical assessment has to be accurate; Ask patient to complete consent form to receive a copy of correspondence to GP; Complete the checking of information, ethnicity and accommodation forms; Ensure admin staff have recorded the referral on the daily referral log sheet; Complete contact record for computerised notes (RiO) which admin staff then enter; Brief letter to the GP faxed on the day of assessment for self harm; Full assessment letter at time of discharge from the team for patients seen for reasons other than self harm; Complete audit assessment form post discharge (Appendix 6); Dictate letter to the referrer, GP, patient and other professionals involved in the patient’s care after all initial and final out-patient appointments. Letters should also be sent after each appointment with medical staff and at intervals or if significant new information arises during intensive psychosocial interventions undertaken by practitioners.

USE OF THE MENTAL HEALTH ACT IN THE GENERAL HOSPITAL
If a patient is transferred from a mental health in-patient unit whilst detained under the Mental Health Act (MHA), responsibility remains with the mental health trust if the patient has been transferred under section 17 leave. The doctor responsible for the patient’s mental health care (Responsible Clinician as defined by the MHA) remains the Consultant Psychiatrist, or other professional if they are the RC, in the mental health unit. DPM clinical staff will liaise with the in-patient unit regarding mental health assessment and will complete a weekly summary to fax to the mental health unit for discussion of the patient in ward rounds. If a patient is detained under the MHA whilst in General Hospital, then General Hospital has legal responsibility for mental health care. They will therefore have responsibility for arranging tribunals etc. The section papers need to be formally received by the site co-ordinator in SGH for the section to be valid. Section 5(2) is a doctor’s holding power and can be applied by any fully registered medical practitioner (not FY1 doctor) to detain any admitted patient (not anyone in the Emergency Department) who the doctor suspects of having a mental illness necessitating detention under a more prolonged section of the MHA. When the section is placed, the site co-ordinator should be involved and they should notify the Approved Mental Health Practitioners (AMHPs) in Southampton Home Treatment Service so that a full MHA assessment can be arranged. The section 5(2) lasts up to 72 hours. Sections 2 and 3 of the MHA enable detention for 28 days for assessment or 6 months for treatment of a mental disorder. They only provide legal power to treat physical problems if these are a direct cause or consequence of the mental disorder. The site co-ordinators will fax a notification of sectioning using section 2 or 3 of the MHA to the Department of Psychological Medicine the next working day. The Liaison Psychiatrist (LP - Dr Butler) will take on the MHA role of Responsible Clinician for adults aged years. For older adults a clinician in DPM needs to speak to the relevant OPMH Consultant to take on the Responsible Clinician role. For leave periods, LP (Dr Butler) will have notified the team of the Consultant Psychiatrist covering the Responsible Clinician role. For section 2 or 3, only the Responsible Clinician (LP or other nominated Consultant Psychiatrist) can allow leave from General Hospital grounds (which needs a section 17 leave form completing) or discharge of the section. As for other patients, clinicians in DPM have a responsibility to advise General Hospital on levels of observation, psychiatric treatment and other management of the mental health problems for patients detained under the MHA in General Hospital.

OPMH Medication Management
Depression treatment guidelines for Older Adults Antidementia drug treatment guidelines Guidelines for Rapid Tranquilisation for Older Adults Prescribing Lithium Oral Antipsychotics Prescribing guidelines for treatment of behavioural problems in Dementia DVLA Guidelines on fitness to drive Choice and Medication (UK Psychiatric Pharmacists Information site) Medicines Control, Administration and Prescribing Policy Antibiotic Prescribing Guidelines Cholesterol Guidelines Clozapine initiation – inpatient & community Prescribing guidelines for BPD (under development) Risperdal Consta forms &monitoring guidance for clients receiving treatment for psychosis ECT

OPMH Community intervention
Memory Nurse Assessment Care Planning Care Coordination Intervention Liaison Day Therapy Nurse Intervention, individual and group Psychiatrist Psychiatric assessment Risk management Diagnosis Medication management Care coordination Psychologist Psychological assessment Cognitive Assessment Psychological intervention Psychological formulation, training & supervision Occupational therapist Occupational Assessment including AMPS Health Care Support worker Engagement Social intervention Documentation Social Worker Social needs Assessment Care Planning Care Coordination Care Management Liaison Community mental Health Nurse Assessment Intervention Nursing and Residential Home Liaison Acute Hospital Liaison

Care Pathway – Emotional difficulties (‘borderline personality disorder’)
Prominent psychotic symptoms Exit from services Psychosis pathway Problem -solving guidance Specialist service Specific outcome measure (CORE) Review Requires Mental Health Service intervention Specific outcome measure Review NICE priorities Community pathway Medication review Assessment & risk management Confirm diagnosis Personal Validation Psychol -ogical review Assertive outreach/ Recovery team Requires maintenance support Acute care pathway Not require Mental Health Service intervention CMHT Self-help & caring NICE guideline CG78 PbR cluster Emergence

difficulties’ pathway
Care Pathway – Psychosis Specific outcome measures (Positive & Negative symptoms) Co-existing ‘borderline p.d.’ Exit from services ‘Emotional difficulties’ pathway Co-existing substance misuse Substance misuse pathway Requires Mental Health Service intervention Specific outcome measure Early intervention Review NICE priorities Medication review Assessment & risk management Community pathway Consider diagnosis Psycho social review Assertive outreach/ Recovery team Requires maintenance support Acute care pathway Not require Mental Health Service intervention CMHT Self-help & caring NICE guideline CG82 (for co-existing drug misuse – awaited) PbR clusters

Care Pathway – Bipolar Disorder
Exit from services Co-existing substance misuse Specific outcome measures (Mania & Depression) Substance misuse pathway Requires Mental Health Service intervention Specific outcome measures Early intervention Review NICE priorities Medication review Assessment & risk management Community pathway Consider diagnosis Psycho social review Assertive outreach/ Recovery team Requires maintenance support Acute care pathway Not require Mental Health Service intervention CMHT Self-help & caring Perinatal period NICE guideline CG38 PbR clusters

Care Pathway – Early Memory Difficulties
Exit from services Dementia Affecting Independent Living Dementia Affecting Independent Living Pathway Specific outcome measure - HoNOS 65+ Specific outcome measures – HoNOS 65+ Psychological and carers support Review Review Memory Assessment Service Criteria Requires Mental Health Service intervention Precription and review of medication Community pathway Assessment & risk management Consider diagnosis Memory Matters Memory Clinic Requires maintenance support Memory Assessment Service CMHT Not require Mental Health Service intervention Self-help & caring NICE guideline CG42 PbR cluster 18

Multi-Professional Care Planning
Care Pathway – Memory Assessment Service (Cognitive impairment -Low need) PbR Cluster 18 Exit form services Psychological support Multi-Professional Care Planning Prescription and monitoring of medication Review Care Pathway Criteria Memory Matters Memory problems not affecting Independent living Specific outcome measure HoNOS 65+ Specific outcome measure HoNOS 65+ Carer Support Care Pathway Criteria & Risk assessment Clinical assessment Memory problems affecting Independent living Community Pathway (Moderate need) Memory Problems not requiring Mental Health service intervention NICE guideline for Self-help & caring Dementia – CG 42

Multi-Professional Care Planning
Care Pathway – Complicated cognitive impairment or Dementia (Moderate Need) PbR Cluster 19 Complicated Dementia with high level of need Pathway Exit form services High Psychological and occupational therapy interventions High or moderate level of need? Multi-Professional Care Planning Moderate Prescription and monitoring of medication Review Care Pathway Criteria Memory problems affecting Independent living Joint working with partner organisations Specific outcome measure HoNOS 65+ Specific outcome measure HoNOS 65+ Care Pathway Criteria & Risk Assessment Additional care provided at home Clinical assessment Carer Support Memory assessment service pathway Memory problems not affecting Independent living NICE guideline for Dementia – CG 42 Self-help & caring

Multi-Professional care planning
Care Pathway – Complicated cognitive impairment or Dementia (High Need) PbR Cluster 20 Complicated Dementia with high level of physical need/Engagement Pathway Exit form services Psychological/therapeutic Interventions Yes High level of physical Need/ engagement? Multi-Professional care planning Prescription and monitoring of medication no Additional care provided at home Continuing Health Care Assessment Review Care Pathway Criteria Psychiatric inpatient assessment Specific outcome measure HoNOS 65+ Specific outcome measure HoNOS 65+ Memory problems affecting Independent living (high need) Acute hospital treatment Care Pathway Criteria & Risk Assessment Clinical & social care assessment Adult Services respite Carer Support Memory problems affecting Independent living (moderate need) Community Pathway (Moderate need) NICE guideline for Self-help & caring Dementia – CG 42

Multi-Professional care planning
Care Pathway – Cognitive Impairment or Dementia (High Physical Need/Engagement) PbR Cluster 21 Psychological/therapeutic Interventions Multi-Professional care planning Exit form services Medication for behaviour that challenges Continuing Health Care Assessment End of Life Care Pathway Intensive home care support Psychiatric inpatient assessment Review Care Pathway Criteria Memory problems affecting Independent living (High Physical need/Engagement) Specific outcome measure HoNOS 65+ Specific outcome measure HoNOS 65+ Acute hospital treatment Nursing or Residential home placement Care Pathway Criteria & Risk Assessment Clinical & social care assessment Carer Support Memory problems affecting Independent living (High need) Complicated Dementia with high level of need Pathway NICE guideline for Self-help & caring Dementia – CG 42

difficulties’ pathway
Care Pathway – Eating disorders Co-existing ‘borderline p.d.’ Exit from services ‘Emotional difficulties’ pathway SCOFF (screening questionnaire) Co-existing substance misuse Substance misuse pathway Specific outcome measures Requires Mental Health Service intervention Specific outcome measure Eating Disorder Service REVIEW NICE PRIORITIES Medication review Assessment & risk management Community pathway Consider diagnosis Psycho social review Assertive outreach/ Recovery team Requires maintenance support Acute care pathway Not require Mental Health Service intervention CMHT BMI calculator Self-help & caring NICE guideline (CG9) Payment-by-results (Cluster 6)

Medication Management
Antibiotic Prescribing Guidelines Cholesterol Guidelines Choice and Medication (UK Psychiatric Pharmacists Information site) Clozapine initiation – inpatient & community DVLA Guidelines on fitness to drive Guidelines for Rapid Tranquilisation Medicines Control, Administration and Prescribing Policy Oral Antipsychotics Prescribing guidelines for BPD (under development) Prescribing Lithium Risperdal Consta forms &monitoring guidance for clients receiving treatment for psychosis ECT User info Choice and Medication MIND

Psychosocial interventions
All pathways (psychosis) Emotional difficulties Psychosis Cognitive therapy (CBT, CAT) 6, 12, 16, 20, 24, 1 & 2 yr sessions Dialectical behaviour therapy (DBT) 48 group session group & 51 individual sessions Psychodynamic psychotherapy Group & 20 sessions, 1 & 2 yr Arts therapies (Art, music, dance) 20 sessions Family & Couples therapy 3, 6 & 10 sessions Problem-solving, Motivational interviewing; Assertiveness & Social Skills Training, Anger, & Anxiety management All eligible patients should be offered PI. Patient choice, non-response to previous therapy & medication, and severity determine ‘dosage’ and expertise of therapist.

Community intervention
Support worker Caseload 10-20 Care coordinator Caseload 30 (CMHT) Caseload 15 (EIP) Caseload 10 (AOT) Team (CRHT) Psychiatrist Caseload (estimate) Psychologist Roles Engagement Social intervention Documentation Roles (include above) Assessment Intervention Liaison Psychiatric assessment Risk management Diagnosis Medication management Care coordination Psychological intervention Psychological formulation, training & supervision

PbR Clusters & Care Pathways1
Clusters represent stages in CPs Emotional difficulties: 1: Common Mental Health Problems (low severity) 2: Common Mental Health Problems (low severity with greater need) 3: Non-Psychotic (Moderate Severity) 4: Non-Psychotic (Severe) 5: Non-Psychotic (very severe) 7: Enduring Non-Psychotic Disorders (high disability) 15. Severe Psychotic Depression 6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD] 8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’] Psychosis: 10: First Episode in Psychosis 14: Psychotic Crisis 11: Ongoing Recurrent Psychosis (low symptoms) 12: Ongoing or Recurrent Psychosis (high disability) 13: Ongoing or Recurrent Psychosis (high symptom and disability) 16: Dual Diagnosis = ‘Psychosis with drug abuse’ 17: Psychosis and Affective Disorder Difficult to Engage Memory difficulties: 18: Cognitive impairment (low need) 19: Cognitive impairment or Dementia Complicated (Moderate need) 20: Cognitive impairment or Dementia Complicated (High need) 21: Cognitive impairment or Dementia (High physical or engagement needs) 1Cluster 9 is blank

Mental Health Training
General practice basic CPD GMC Management basic CPD Mental health practitioner basic CPD Nursing basic CPD NMC Occupational Therapist basic CPD Psychiatry basic CPD GMC MRCPsych course (Wsx) Psychology basic CPD Social work basic CPD GSCC Medical students Portal (Soton) OSCE HPFT Training

Borderline Personality Disorder

Bipolar Affective Disorder

Antenatal and Postnatal (CG45)

Anxiety Disorders

Depression

Post Traumatic Stress Disorder

Obsessive-Compulsive and Body Dysmorphic Disorders

Eating disorders

Perinatal bipolar disorder NICE guidelines

Bipolar Care pathway Perinatal Service pathway NICE guidelines
Bipolar CG38 Perinatal CG45 Perinatal Service pathway

Developed by SLAM 2010

Five ways to well-being
1. Connect… With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in your local community. Think of these as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day. 2. Be active… Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance. Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness. 3. Take notice… Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you. 4. Keep learning… Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you enjoy achieving. Learning new things will make you more confident as well as being fun. 5. Give … Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, as linked to the wider community can be incredibly rewarding and creates connections with the people around you. The Big White Wall The support network

Mental Health Care Pathway (prototype)

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Mental Health Care Pathway (prototype)

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