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Mental Health Care Pathway (prototype) Self-help & CaringCaring Primary care Other agencies Psychological Therapy Services (IAPT) Mental health services.

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Presentation on theme: "Mental Health Care Pathway (prototype) Self-help & CaringCaring Primary care Other agencies Psychological Therapy Services (IAPT) Mental health services."— Presentation transcript:

1 Mental Health Care Pathway (prototype) Self-help & CaringCaring Primary care Other agencies Psychological Therapy Services (IAPT) Mental health services Service Pathways HantsHants OxonOxon Care pathways MENTAL HEALTH iiii Commissioning for mental health General hospital services Coping with daily living problems Exit from services Coping with daily living problems

2 Mental Health Care Pathway Please insert UK postcode for locaised information Mental health Services Children Adults Older people Learning disability Diagnoses Search Help 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 Comments: Coping with daily living problems Exit from services Self-help & Caring forCaring mental health problems Primary care Mental health Other agencies which work with mental health services How do I contact Psychological Psychological Therapy Services (IAPT)Therapy Services (IAPT)? How do I find mental healthental health ServicesServices? Service pathways through mental health services Care pathways for mental health problems General hospital ServicesServices and Mental health

3 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 for which grateful thanks

4 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.NHS ChoicesNHS Direct –If not under the care of services, contact should be through the persons 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. NHS Direct police –A relative of a patient can ask local mental health services for a Mental Health Act assessment by a psychiatrist and approved mental health practitionerMental Health Act 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 ).NHS Choices –Some services accept self-referral (e.g. Psychological Therapy Services, Drugs & Alcohol or Early Intervention in Psychosis teams)Psychological Therapy Services –Some people are referred from the Courts, Prisons or by the Police.

5 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.

6 Primary Care (including general practitioner or family doctor services) GPs provide front-line mental health care as part of their service to their patients.front-line mental health care 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.such referrals are possible Quality & Outcomes Framework

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

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

9 Partner Agencies Statutory: Police –HampshireHampshire –Thames ValleyThames Valley Councils –HampshireHampshire –OxfordshireOxfordshire –SouthamptonSouthampton General Hospitals –Hampshire Southampton University Hospital TrustSouthampton University Hospital T Royal Hampshire County Hospital Basingstoke Hospital –Oxfordshire Radcliffe Voluntary: National –AgeUKAgeUK –Alcohol ConcernAlcohol Concern –Alzheimers societyAlzheimers society –Centre for Mental HealthCentre for Mental Health –MENCAPMENCAP –Mental Health FoundationMental Health Foundation –MINDMIND –RETHINKRETHINK –Voluntary ServicesVoluntary Services –YOUNG MINDSYOUNG MINDS Local –MIND (Oxon Solent)OxonSolent –Restore (Oxon)Oxon) –No Limits (Soton)(Soton) –Voluntary Services (Oxon Soton)OxonSoton Housing & Employment –City limits (Soton)(Soton) –ShelterShelter

10 For further help: Mental Health Care Pathways Patient rated outcome measure Assistance with coping with lifes problems Leisure activities Work Caring for others Relationships Memoryemory problems Physical health Money Mental distress Spiritual issues General practical advice Cultural support Education Housing issues DrugsDrugs & Alcohol DropByDropBy

11 Housing issues National organisations –ShelterShelter –CrisisCrisis –Homeless LinkHomeless Link Gateways to homelessness services: –Homeless Healthcare Services (Soton)Soton –Street Homeless Prevention Team (Soton)(Soton) No-One Left Out: Communities Ending Rough SleepingNo-One Left Out Mental health and homelessness good practice guidegood practice guide Asylum seekersAsylum

12 GENERAL HOSPITAL SERVICES Ambulance Services Emergency Department –Access to mental health servicesAccess to mental health services –Management of Deliberate Self-Harm Perinatal (mother & baby) mental health carePerinatal Psychological medicine (General hospital liaison) (General hospital liaison) Mental Health Act, Mental Capacity & Deprivation of liberty (DOLS) guidanceMental Health ActMental Capacity(DOLS) Specific conditions –Dementia & DeliriumDementia –Physically unexplained symptomsPhysically unexplained symptoms –Other mental health conditionsOther mental health conditions Local Hospitals

13 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.books & leaflets diagnostic systems

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

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

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

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

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

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

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

21 Mental health pathway Memory assessment pathway Early Memory Difficulties Memory Difficulties R&D R&D ( diagnosis) diagnosis Global outcome measure Global outcome measure – HoNOS 65+ Global outcome measureGlobal outcome measure – HoNOS 65+ Care Pathway s – Memory Difficulties Moderate need pathway High physical or engagement need pathway High need pathway Review priorities Review priorities Review priorities Review priorities Review priorities Self-help & caringcaring

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

23 DIALOG 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? 1.Couldnt be worse 2.Displeased 3.Mostly dissatisfied 4.Mixed 5.Mostly satisfied 6.Pleased 7.Couldnt be better 8.No response Additional help required? Yes/No ……………………………………. Recovery Star

24 Self-help GENERAL INFO Books NHS Choices MIND MENCAP RETHINK Choice and Medication Royal College of Psychiatrists SUBSTANCE MISUSE Books Talk-to-Frank (drugsTalk-to-Frank (drugs) Drinkaware Alcoholics Anonymous Alcohol Concern NHS Choices 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 EMOTIONAL DIFFICULTIES Books NHS Choices Computerised CBT Royal College of Psychiatrists

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

26 Emotional difficultiesPsychosis Memory difficulties Developmental difficulties Substance misuse

27 Developed by SLAM

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

29 Acute care pathway REFERRAL Single point of access & rapid response by Crisis Resolution Home Treatment Team (CRHT) Assessment Assessment involving SU, carer and relevant others (risk issues including safeguarding children and adults)carerrisk issues childrenadults Consider Mental Health Act, Capacity & Deprivation of liberty (DOLS)Mental Health ActCapacity(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 GPother servicessignpost PICU InpatientCRHT BUILD ON INITIAL ASSESSMENT (INCLUDING RISK) AND BEGIN RECOVERY AND STRENGTHS FOCUSSED THERAPEUTIC APPROACH WITH SERVICE USER INVOLVEMENT

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

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

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

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

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

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

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

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

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

39 OPMH Community pathway Assessment REFERRAL Provide single point of access Rapid response proportional to urgency Assessment Assessment involving patient, carer and relevant others (also risk issue including safeguarding children,adults)carerchildrenadults RISK ASSESSMENT, HoNOS REFERRAL OUTCOMES Brief intervention (include Liaison Team involvement). Accept referral & allocate care co- ordinator Engage other services/signpostother servicessignpost Enter inpatient pathway 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.

40 OPMH Community Pathway INITIATING CARE Arrange appointment, either at home or community base Engage Carer 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 advocacywork Develop treatment objectives & timescale Commence Care PlanningCare Planning Consider self-directed support (personalisation)self-directed support Communicate with referrer & GP

41 OPMH Community pathway TREATMENT Formulate problems/diagnosis. Identify interventions and time frame. (Care Planning) Practical help with basics of daily living and crisis planPractical help Consider psychiatric review & review medicationmedication Consider fitness to drive or use machineryfitness to drive Reconsider self-directed support (personalisation)self-directed support 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 agencieswork CPA review (repeat HoNOS)CPAHoNOS Physical needs reassessment Ongoing Risk Assessment Consider MHA & need for acute pathwayMHAacute pathway Side effect monitoring, improve concordanceSide effect monitoring Caseload & clinical supervision Report & manage any complaintscomplaints Review NICE guideline for condition Regular communication with GP, accommodation provider & carer

42 DISCHARGE/TRANSFER Consider whether criteria for discharge are met Engage CarerEngage Carer/carer support worker Consider input required from Adult Services and other agencies Agree discharge date Prepare for discharge/transfer CPACPA review with relapse prevention planrelapse prevention plan HoNOSHoNOS on discharge Communicate with GP OPMH Community pathway

43 Eating Disorder Service Pathway REFERRAL Waiting list INTERVENTIONS REVIEW NICE PRIORITIES DISCHARGE 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.Assessment carerrisk issues Consider Mental Health Act & Deprivation of liberty (DOLS)Mental Health Act(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 GPother servicessignpost INTERVENTIONS Outpatient, day care (12 weeks) or Inpatient (Acute Care Pathway or General Hospital)Acute Care Pathway 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 interventionsPsychological 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 DISCHARGE Engage Carer/care support workerCarer Agree discharge date Prepare for discharge/transfer Consider active involvement of CRHT & input required from social care, work and other agencieswork CPACPA joint review with care coordinator/community consultant including relapse prevention planrelapse prevention plan HoNOSHoNOS on discharge Agree follow-up: Outpatient, CRHT & Care Co-ordinator Discharge summary (within 2 weeks)

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

45 General Hospital Liaison Service Pathway REFERRAL PROCESS (in-patient & outpatient) REFERRAL ROUTE REFERRAL CRITERIA TEAM RESPONSE 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 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 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 Mental health assessment should be arranged by the patients GP or rarely Emergency Department, who can then access community mental health resources if required. 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

46 General Hospital Liaison Service Pathway REFERRAL PROCESS REFERRAL ROUTE REFERRAL CRITERIA MENTAL HEALTH INTERVENTION 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. 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 patients 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. 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)

47 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 patients 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 doctors 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.

48 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)Choice and Medication Medicines Control, Administration and Prescribing Policy Antibiotic Prescribing Guidelines Cholesterol Guidelines Clozapine initiation – inpatient & communityClozapine initiation – inpatientcommunity Prescribing guidelines for BPD (under development) Risperdal Consta forms &monitoring guidance for clients receiving treatment for psychosisRisperdal Consta forms &monitoring guidance for clients receiving treatment for psychosis ECT

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

50 Confirm diagnosis Prominent psychotic symptoms Problem -solving guidance Community pathway Not require Mental Health Service intervention Requires Mental Health Service intervention Medication review Psychol -ogical review Specialist service Acute care pathway Exit from services NICE guideline CG78CG78 Psychosis pathway Assessment & risk management Review Care Pathway – Emotional difficulties (borderline personality disorder) (borderline personality disorder) PbR cluster Specific outcome measure ( CORE ) CORE Specific outcome measure Review NICE priorities Requires maintenance support Assertive outreach/ Recovery team CMHT Self-help & caringcaring Emergence

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

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

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

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

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

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

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

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

59 Medication Management Antibiotic Prescribing Guidelines Cholesterol Guidelines Choice and Medication (UK Psychiatric Pharmacists Information site)Choice and Medication Clozapine initiation – inpatient & communityClozapine initiation – inpatientcommunity 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 psychosisRisperdal Consta forms &monitoring guidance for clients receiving treatment for psychosis ECT User info Choice and Medication MIND

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

61 CommunityCommunity intervention Support worker –Caseload Care coordinator –Caseload 30 (CMHT) –Caseload 15 (EIP) –Caseload 10 (AOT) –Team (CRHT) Psychiatrist (estimate) –Caseload (estimate) Psychologist Roles –Engagement –Social intervention –Documentation Roles (include above) –AssessmentAssessment –Intervention –Liaison Roles (include above) –Psychiatric assessment –Risk managementRisk management –Diagnosisiagnosis –Medication managementMedication management –Care coordination Roles –Psychological interventionPsychological intervention –Psychological formulation, training & supervision

62 PbRPbR Clusters & Care Pathways 1 Clusters represent stages in CPs –Emotional difficulties: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: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: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) 1 Cluster 9 is blank

63 Mental Health Training General practicebasic CPD GMCbasic CPDGMC Management basicCPDbasicCPD Mental health practitionerbasicCPD NursingbasicCPD NMCbasicCPDNMC Occupational TherapistbasicCPDbasicCPD Psychiatrybasic CPD GMC MRCPsych course (Wsx)basicCPDGMC MRCPsych course PsychologybasicCPDbasicCPD Social workbasicCPDGSCCbasicCPDGSCC Medical studentsPortal (Soton) OSCEPortalOSCE Training HPFT

64 Borderline Personality Disorder

65 Bipolar Affective Disorder

66 Antenatal and Postnatal ( CG45) CG45

67 Anxiety Disorders

68 Depression

69 Post Traumatic Stress Disorder

70 Obsessive-Compulsive and Body Dysmorphic Disorders

71 Eating disorders

72 NICE guidelines Perinatal bipolar disorder

73 Bipolar Care pathway NICE guidelines Bipolar CG38CG38 Perinatal CG45CG45 Perinatal Service pathway

74 Developed by SLAM 2010

75 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.

76 See also; PANSSPANSS

77 SCHIZOPHRENIA GUIDELINES CG1 (2009)


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