Presentation on theme: "Mental Health Care Pathway (prototype)"— Presentation transcript:
1 Mental Health Care Pathway (prototype) Self-help& CaringPsychologicalTherapy Services (IAPT)CopingwithdailylivingproblemsCopingwithdailylivingproblemsPrimary careCare pathwaysservicesExit fromMental healthservicesService PathwaysHants OxonGeneral hospitalservicesOther agenciesCommissioningformental healthi
2 Mental Health Care Pathway Mental health Services Children Adults Older people Learning disability Diagnoses Search HelpSelf-help& Caring formental health problemsHow do I contact PsychologicalTherapy Services (IAPT)?Coping withdailylivingproblemsPrimary careMental healthExitfromservicesCare pathwaysfor mental healthproblemsMENTAL HEALTHMENTAL HEALTHGeneral hospitalServices andMental healthHow do I find mental healthServices?Service pathwaysthrough mentalhealth servicesOther agencieswhich work withmental health servicesPlease insert UK postcode forlocaised informationComments: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 individualsfor which grateful thanks (comments welcomed to )
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 toDeveloped by David Kingdon for NHS South Central with contributions from many individualsfor which grateful thanks
4 Getting access to mental health services EmergencyWhere 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).UrgentWhere someone is very distressed or may be talking about harming themselves or someone else, immediate attention may be necessaryIf 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 practitionerRoutineMost 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.
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.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
7 Primary Care NO ACTION ASSESSMENT EPISODE INTERVENTION COMPLETION Explanation of symptoms or sign-posting may be sufficient.Consider watchful waiting for emotional difficulties.NO ACTIONHolistic assessment including both mental and physical state.Consider carer perspectiveConsider diagnosis especially early intervention in psychosisConsider relapse preventionand sign-postingINTERVENTIONASSESSMENTEPISODECOMPLETIONWatchful waiting & self-help resourcesWhere 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 guideREFERRALAccess local psychological therapy services (IAPT) or mental health servicesIf referral refused by patient, consider discussion with local CMHT or early intervention team
8 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.
9 Partner Agencies Statutory: Police Councils General Hospitals HampshireThames ValleyCouncilsOxfordshireSouthamptonGeneral HospitalsSouthampton University Hospital TrustRoyal Hampshire County HospitalBasingstoke HospitalRadcliffeVoluntary:NationalAgeUKAlcohol ConcernAlzheimers societyCentre for Mental HealthMENCAPMental Health FoundationMINDRETHINKVoluntary ServicesYOUNG MINDSLocalMIND (Oxon Solent)Restore (Oxon)No Limits (Soton)Voluntary Services (Oxon Soton)Housing & EmploymentCity limits (Soton)Shelter
10 Assistance with coping with life’s problems PhysicalhealthHousingissuesMoneyMemoryproblemsPatient rated outcome measureDrugs &AlcoholPatient rated outcome measureWorkCaringfor othersRelationshipsGeneralpracticaladviceCulturalsupportEducationLeisureactivitiesMentaldistressSpiritualissuesDropByFor further help:Mental HealthCare PathwaysThe Big White WallThe support network
11 Housing issues National organisations ShelterCrisisHomeless LinkGateways 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 guideAsylum seekers
12 GENERAL HOSPITAL SERVICES Ambulance ServicesEmergency DepartmentAccess to mental health servicesManagement of Deliberate Self-HarmPerinatal (mother & baby) mental health carePsychological medicine (General hospital liaison)Mental Health Act , Mental Capacity & Deprivation of liberty (DOLS) guidanceSpecific conditionsDementia & DeliriumPhysically unexplained symptomsOther mental health conditionsLocal Hospitals
13 Care pathwaysThese are ways of describing the care needed for specific mental health conditions.Broadly these are:Emotional difficulties, usually presenting with distressPsychosis, where there is some confusion or disagreement with others about what is really happeningMemory difficulties, where these may be from changes to the brainDevelopmental difficulties where development has been held back in learning disability or is a problem, e.g. with behaviourSubstance misuse - drug or alcohol problemsMuch fuller information is given in books & leaflets or diagnostic systems.
21 Care Pathways – Memory Difficulties Global outcome measure – HoNOS 65+ReviewprioritiesEarly MemoryDifficultiesMemoryassessmentpathwayReviewprioritiesMentalhealthpathwayModerate needpathwayReviewprioritiesMemoryDifficultiesR&D(diagnosis)Global outcome measure – HoNOS 65+High need pathwayReviewprioritiesHigh physicalor engagementneed pathwayReviewprioritiesSelf-help& caring
22 Quality & Outcomes Framework (mental health) Check your localsurgery resultsResourcesRCGP forumEarly intervention in psychosis
23 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 worseDispleasedMostly dissatisfiedMixedMostly satisfiedPleasedCouldn’t be betterNo responseAdditional help required? Yes/No…………………………………….Recovery Star
24 Self-help SUBSTANCE MISUSE GENERAL Books INFO Talk-to-Frank (drugs) DrinkawareAlcoholics AnonymousAlcohol ConcernNHS ChoicesRoyal College ofPsychiatristsGENERALINFOBooksNHS ChoicesMINDMENCAPRETHINKChoice and MedicationRoyal College ofPsychiatristsEMOTIONALDIFFICULTIESBooksNHS ChoicesComputerised CBTRoyal College ofPsychiatristsPSYCHOSISBooksHearing Voices NetworkRETHINKMINDNHS ChoicesRoyal College ofPsychiatristsMEMORYDIFFICULTIESBooksDementia gatewayNHS ChoicesRoyal College ofPsychiatrists
25 Carers Books Al-Anon (alcohol carers support) Alcohol Concern Caring (finance, etc)Care choicesChoice and MedicationConfidentiality and sharing informationDementia gatewayMental health care (psychosis)Mental health first aidNHS Carers DirectPrincess Royal Trust for CarersRETHINKRoyal College of Psychiatrists
29 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 possibleREFERRAL OUTCOMEAdmission to hospitalCRHT careRefer to CMHT or maintenance by current teamEngage other services/signpost Discharge to GPPICU Inpatient CRHTBUILD 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 & GPAssertive EngagementGate KeepingEngage Carer /carer support workerMaintain contact with care co-ordinators (community pathway)Obtain case notes or electronic equivalentConfirm admission objectivesCommence discharge planning with projected discharge date, housing needs & care PlanHoNOS on admissionConsider input required from social, advocacy and other agenciesComplete admission checklist‘Meet and Greet’ establish consent to admissionImmediate risk assessment/support level/ward environmentOrientation to wardIdentify physical needs (e.g. check Body mass index [BMI])If detained read rights
31 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. forensicCommence interventions to include psychological in broad sense (include CBT, interventions to enhance resilience, crisis planning, relapse prevention, problem-solving, anxiety management)Regular MDT reviewConsider input required from social care, advocacy and other agenciesSenior/Professionals’ reviewWard round/Consultant reviewConsider involvement of & early discharge to CRHTManage physical health care needsTREATMENTAssertive engagement, intensive supportTime limited intervention, medication review if needed.Manage self-harm & hostility (include incident & complaint reporting)Practical help with basics of daily living and crisis planUse of Crisis beds when availableEngage Carer/care support workerMaintain contact with care coordinator (community pathway)InvestigationsFormulate problems/diagnosis on bio-psycho-social modelConsider medication and other interventions including ECT
32 Acute care pathway DISCHARGE Engage Carer/care support worker Agree discharge datePrepare for discharge/transferConsider active involvement of CRHT & input required from social care, work and other agenciesCPA joint review with care coordinator/community consultant including relapse prevention planUse of step-down/Crisis beds when availableConsider trial leaveComplete discharge checklistHoNOS on dischargeAgree follow-up: Outpatient, CRHT & Care Co-ordinator (<48hr [high suicide risk] or <7-day)Discharge summary (within 2 weeks)
33 Community pathway DISCHARGE REFERRAL TREATMENT Community Pathway CMHTINITIATINGCARETREATMENTCommunity PathwayQuality & PerformanceDashboard
34 Community pathway REFERRAL Provide single point of access Rapid response proportional to urgencyAssessment involving patient, carer and relevant others (also risk issues including safeguarding children and adults)REFERRAL OUTCOMESBrief intervention (include Discharge Liaison Team involvement).Enter acute care pathwayRefer to specialist team (Early Intervention, Substance Use, Assertive, Rehabilitation)Accept referral & allocate care co-ordinator &/or to outpatient care; engage other services/signpostDischarge to GPCMHTBUILD ON INITIAL ASSESSMENT (INCLUDING RISK) HoNOS AT INITIAL CONTACT.BEGIN RECOVERY AND STRENGTHS FOCUSSED THERAPEUTIC APPROACH WITH SERVICE USER INVOLVEMENT
35 Community Pathway Arrange appointment Assertive Engagement INITIATING CAREArrange appointmentAssertive EngagementEngage Carer /carer support workerDevelop treatment objectives & timescaleCommence Care PlanningConsider input required from social care, work, advocacy, housing and other care agenciesIdentify physical needs (e.g. check Body mass index [BMI])Consider need for psychiatric reviewMental 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
36 Community pathway TREATMENT Formulate problems/diagnosis on bio-psycho-social modelTime limited intervention, medication review if needed.Practical help with basics of daily living and crisis planConsider need for psychiatric review & review medication needsConsider fitness to drive or use machinerySupplement assessment which may include the intervention of other professionals, e.g. psychologist, occupational therapistReconsider 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 agenciesPhysical needs reassessmentContinue to assess risk, MHA& need for acute pathwaySide-effect monitoring, improve concordanceCaseload & clinical supervisionReview NICE guideline for conditionRegular communication with GP, accommodation provider & carer
37 Community pathway DISCHARGE/TRANSFER Consider whether criteria for recovery pathway metEngage Carer/carer support workerConsider input required from social care and other agenciesAgree discharge datePrepare for discharge/transferCPA review with relapse prevention planHoNOS on dischargeCommunicate with GP
38 OPMH Community pathway DISCHARGEREFERRALCMHTINITIATINGCARETREATMENTCommunity PathwayQuality & PerformanceDashboardDropBy
39 OPMH Community pathway Assessment REFERRALProvide single point of accessRapid response proportional to urgencyAssessment involving patient, carer and relevant others (also risk issue including safeguarding children ,adults)RISK ASSESSMENT, HoNOSREFERRAL OUTCOMESBrief intervention (include Liaison Team involvement).Accept referral & allocate care co-ordinatorEngage other services/signpostEnter inpatient pathwayDischarge to GPCMHTMultidisciplinary review.Initiate other assessments- psychology, occupational therapy, nursing ,medicalReview of Risk.Initiate care planning.Liaise with partner organisations- Adult Services, Community Healthcare.
40 OPMH Community Pathway INITIATING CAREArrange appointment, either at home or community baseEngage Carer /carer support workerIdentify further assessments needed- psychological, cognitive assessment, occupational therapy, physical health assessment.Consider need for psychiatric review includingMental Health Act assessment .Identify need for investigations, blood test or scanning. Consider referral to Adult Services, care agencies, advocacy, workDevelop treatment objectives & timescaleCommence Care PlanningConsider self-directed support (personalisation)Communicate with referrer & GP
41 OPMH Community pathway TREATMENTFormulate problems/diagnosis.Identify interventions and time frame. (Care Planning)Practical help with basics of daily living and crisis planConsider psychiatric review & review medicationConsider fitness to drive or use machineryReconsider self-directed support (personalisation)Psychological interventionsincluding cognitive work, CBT, crisis planning, relapse prevention, problem solving, stress managementOccupational interventions to support independent livingConsider input required from adult services, work and other agenciesCPA review (repeat HoNOS)Physical needs reassessmentOngoing Risk AssessmentConsider MHA & need for acute pathwaySide effect monitoring, improve concordanceCaseload & clinical supervision Report & manage any complaintsReview NICE guideline for conditionRegular communication with GP, accommodation provider & carer
42 OPMH Community pathway DISCHARGE/TRANSFERConsider whether criteria for discharge are metEngage Carer/carer support workerConsider input required from Adult Services and other agenciesAgree discharge datePrepare for discharge/transferCPA review with relapse prevention planHoNOS on dischargeCommunicate with GP
43 Eating Disorder Service Pathway DISCHARGEEngage Carer/care support workerAgree discharge datePrepare for discharge/transferConsider active involvement of CRHT & input required from social care, work and other agenciesCPA joint review with care coordinator/community consultant including relapse prevention planHoNOS on dischargeAgree follow-up: Outpatient, CRHT & Care Co-ordinatorDischarge summary (within 2 weeks)INTERVENTIONSOutpatient, day care (12 weeks) or Inpatient (Acute Care Pathway or General Hospital)1st session measures:CPA reviewPhysical monitor with relevant investigations (coordinated with GP)Guided self-help: 4 month – 6 direct contactsNutritional adviceGroup workMedication reviewPsychological interventions: Family therapy, Group work, DBT modified, individual & group; Inter-personal therapy – 24 sessions: CBT – 20 sessionsCAT – 16, 24, or 32 sessions: Measure CORE-10REFERRALWaiting listINTERVENTIONSDISCHARGEREVIEWNICEPRIORITIESREFERRALScreening: Assess comorbidities jointly with CMHTInform referrerComprehensive 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 userREFERRAL OUTCOMETaken onto waiting list by Eating disorder serviceRefer to CMHT or maintenance by current teamEngage other services/signpost Discharge to GP
44 Early Intervention in Psychosis Service Pathway First presentation for assessment of psychosis(aged 14-35)24 hour accessProvide service & self-help materialsComplete specific outcome measures:PANSS, GAF, HADS, Drake.Follow COMMUNITY & PSYCHOSIS PATHWAYSFocus on psychological and family work.Carer supportAssertive care coordinationMedication managementOutreach to schools, colleges,youth organisations, GPs, etcUrgentACUTECAREPATHWAYREFERRALTAKEN ON BYEIT(up to 36 months)REFERRAL OUTCOMEASSESSMENT BY EIT(up to 6 months)Non-Urgent(within 7 days)EIPASSESSMENTNO PSYCHOSISEarlyinterventionSites[IRIS,EPPIC]Refer on to CMHT or other mental health service or back to GP or referrer
45 General Hospital Liaison Service Pathway REFERRALS FROM WARDS AND THE EMERGENCY DEPARTMENTAccepted from medical staff responsible for the patient between: 09:00 – 17:00hrs, Monday to Friday for 18 – 65 year oldsIf the referral is received after 16:00:-There will be provision of initial advice and assessment if there is a clinical crisisReferrals from the Emergency Department to the Home Treatment Service if the patient is expected to become medically fit for discharge later in the eveningAssess 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 deterioratesREFERRALS TO PSYCHOLOGICAL MEDICINE OUT-PATIENT CLINICReferrals 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 HospitalREFERRALPROCESS(in-patient & outpatient)TEAMRESPONSEREFERRAL ROUTEREFERRAL CRITERIAREFERRALS OUTSIDE THE WORKING HOURS OF THE TEAMOnly 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 ServiceCrisis referrals from General Hospital out-patient clinics or occupational healthMental 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 CRITERIAAll 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
46 General Hospital Liaison Service Pathway TEAM RESPONSE TO REFERRALSOn 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 ROUTEReferrals 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 investigationsIf 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 teamPrioritisation 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)REFERRALPROCESSMENTAL HEALTHINTERVENTIONREFERRAL ROUTEREFERRAL CRITERIATRANSFER TO GENERAL HOSPITAL FROM A MENTAL HEALTH IN-PATIENT UNITHPFT 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 DOCUMENTATIONTeam 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.
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 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.
48 OPMH Medication Management Depression treatment guidelines for Older AdultsAntidementia drug treatment guidelinesGuidelines for Rapid Tranquilisation for Older AdultsPrescribing LithiumOral AntipsychoticsPrescribing guidelines for treatment of behavioural problems in DementiaDVLA Guidelines on fitness to driveChoice and Medication (UK Psychiatric Pharmacists Information site)Medicines Control, Administration and Prescribing PolicyAntibiotic Prescribing GuidelinesCholesterol GuidelinesClozapine initiation – inpatient & communityPrescribing guidelines for BPD (under development)Risperdal Consta forms &monitoring guidance for clients receiving treatment for psychosisECT
49 OPMH Community intervention Memory NurseAssessmentCare PlanningCare CoordinationInterventionLiaisonDay Therapy NurseIntervention, individual and groupPsychiatristPsychiatric assessmentRisk managementDiagnosisMedication managementCare coordinationPsychologistPsychological assessmentCognitive AssessmentPsychological interventionPsychological formulation, training & supervisionOccupational therapistOccupational Assessment including AMPSHealth Care Support workerEngagementSocial interventionDocumentationSocial WorkerSocial needs AssessmentCare PlanningCare CoordinationCare ManagementLiaisonCommunity mental Health NurseAssessmentInterventionNursing and Residential Home LiaisonAcute Hospital Liaison
54 Multi-Professional Care Planning Care Pathway – Memory Assessment Service (Cognitive impairment -Low need)PbRCluster 18Exit form servicesPsychological supportMulti-Professional Care PlanningPrescription and monitoring of medicationReviewCare PathwayCriteriaMemory MattersMemory problems not affecting Independent livingSpecific outcome measure HoNOS 65+Specific outcome measure HoNOS 65+Carer SupportCare PathwayCriteria & RiskassessmentClinical assessmentMemory problems affecting Independent livingCommunity Pathway(Moderate need)Memory Problems not requiring Mental Health service interventionNICE guideline forSelf-help& caringDementia–CG 42
55 Multi-Professional Care Planning Care Pathway – Complicated cognitive impairment or Dementia (Moderate Need)PbRCluster 19Complicated Dementia with high level of need PathwayExit form servicesHighPsychological and occupational therapy interventionsHigh ormoderatelevel ofneed?Multi-Professional Care PlanningModeratePrescription and monitoring of medicationReviewCare PathwayCriteriaMemory problems affecting Independent livingJoint working with partner organisationsSpecific outcome measure HoNOS 65+Specific outcome measure HoNOS 65+Care PathwayCriteria & RiskAssessmentAdditional care provided at homeClinical assessmentCarer SupportMemory assessment service pathwayMemory problems not affecting Independent livingNICE guideline forDementia–CG 42Self-help& caring
56 Multi-Professional care planning Care Pathway – Complicated cognitive impairmentor Dementia (High Need)PbRCluster 20Complicated Dementia with high level of physical need/Engagement PathwayExit form servicesPsychological/therapeutic InterventionsYesHigh levelof physical Need/engagement?Multi-Professional care planningPrescription and monitoring of medicationnoAdditional care provided at homeContinuingHealth CareAssessmentReviewCare PathwayCriteriaPsychiatric inpatient assessmentSpecific outcome measure HoNOS 65+Specific outcome measure HoNOS 65+Memory problems affecting Independent living (high need)Acute hospital treatmentCare PathwayCriteria & RiskAssessmentClinical & social care assessmentAdult Services respiteCarer SupportMemory problems affecting Independent living (moderate need)Community Pathway(Moderate need)NICE guideline forSelf-help& caringDementia–CG 42
57 Multi-Professional care planning Care Pathway – Cognitive Impairment or Dementia (High Physical Need/Engagement)PbRCluster 21Psychological/therapeutic InterventionsMulti-Professional care planningExit form servicesMedication for behaviour that challengesContinuingHealth CareAssessmentEnd of Life Care PathwayIntensive home care supportPsychiatric inpatient assessmentReviewCare PathwayCriteriaMemory problems affecting Independent living (High Physical need/Engagement)Specific outcome measure HoNOS 65+Specific outcome measure HoNOS 65+Acute hospital treatmentNursing or Residential home placementCare PathwayCriteria & RiskAssessmentClinical & social care assessmentCarer SupportMemory problems affecting Independent living (High need)Complicated Dementia with high level of need PathwayNICE guideline forSelf-help& caringDementia–CG 42
59 Medication Management Antibiotic Prescribing GuidelinesCholesterol GuidelinesChoice and Medication (UK Psychiatric Pharmacists Information site)Clozapine initiation – inpatient & communityDVLA Guidelines on fitness to driveGuidelines for Rapid TranquilisationMedicines Control, Administration and Prescribing PolicyOral AntipsychoticsPrescribing guidelines for BPD (under development)Prescribing LithiumRisperdal Consta forms &monitoring guidance for clients receiving treatment for psychosisECTUser infoChoice and MedicationMIND
60 Psychosocial interventions All pathways(psychosis)Emotional difficultiesPsychosisCognitive therapy (CBT, CAT)6, 12, 16, 20, 24, 1 & 2 yr sessionsDialectical behaviour therapy (DBT)48 group session group & 51 individual sessionsPsychodynamic psychotherapyGroup & 20 sessions, 1 & 2 yrArts therapies (Art, music, dance)20 sessionsFamily & Couples therapy3, 6 & 10 sessionsProblem-solving, Motivational interviewing; Assertiveness & Social Skills Training, Anger, & Anxiety managementAll eligible patients should be offered PI. Patient choice, non-response to previous therapy& medication, and severity determine ‘dosage’ and expertise of therapist.
61 Community intervention Support workerCaseload 10-20Care coordinatorCaseload 30 (CMHT)Caseload 15 (EIP)Caseload 10 (AOT)Team (CRHT)PsychiatristCaseload (estimate)PsychologistRolesEngagementSocial interventionDocumentationRoles (include above)AssessmentInterventionLiaisonPsychiatric assessmentRisk managementDiagnosisMedication managementCare coordinationPsychological interventionPsychological formulation, training & supervision
62 PbR Clusters & Care Pathways1 Clusters represent stages in CPsEmotional 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 Depression6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]Psychosis:10: First Episode in Psychosis14: Psychotic Crisis11: 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 EngageMemory 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
63 Mental Health Training General practice basic CPD GMCManagement basic CPDMental health practitioner basic CPDNursing basic CPD NMCOccupational Therapist basic CPDPsychiatry basic CPD GMC MRCPsych course (Wsx)Psychology basic CPDSocial work basic CPD GSCCMedical students Portal (Soton) OSCEHPFTTraining
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.The Big White WallThe support network