A framework for community based mental health services 8 th October 2008 Mervyn Morris Professor of Community Mental Health Professor II, U.C. Buskerud, Norway Director, Centre for Community Mental Health Birmingham City University

Developing a framework Development of effective individual community teams requires consideration of the impact on the whole system. Development of effective individual community teams requires consideration of the impact on the whole system. In Birmingham community team development was part of total service re-design; re-organisation of services and re- allocation of resources. In Birmingham community team development was part of total service re-design; re-organisation of services and re- allocation of resources. There was an intentional shift of the centre of the service away from hospital into the community. This has had a significant impact on the function of the hospital too. There was an intentional shift of the centre of the service away from hospital into the community. This has had a significant impact on the function of the hospital too.

Developing a framework Shift focus from hospital to community: Functionalise community in same way that hospital was/is ‘functionalised’, i.e. separate specialised service or team. Functionalise community in same way that hospital was/is ‘functionalised’, i.e. separate specialised service or team. Emphasis on multi-disciplinary team working; social care integrated Emphasis on multi-disciplinary team working; social care integrated Identifying clear roles and boundaries between functions i.e. teams Identifying clear roles and boundaries between functions i.e. teams

Developing a framework Some key issues: A system of filters and gateways A system of filters and gateways Fidelity Fidelity Staff training Staff training

HOSPITAL Continuing needs: REHABILITATION wards LONG STAY wards ACUTE/ admission wards Out-patients department COMMUNITY PRIMARY CARE & AFTERCARE SERVICE Counselling &Depot injections PsychotherapyResidential care support Once upon a time..

Why develop community based mental health services? De-institutionalisation De-institutionalisation New Models of Community Mental Health New Models of Community Mental Health Human Rights and Values Human Rights and Values National Mental Health Policy National Mental Health Policy Expanding remit of mental health Expanding remit of mental health Consumer/ User/ Carer Views Consumer/ User/ Carer Views

The ‘functionalised’ community model  Primary Care Liaison  Short term Care: Crisis/ Home Treatment Service Residential Services; hospital etc.  Continuing Care: Rehabilitation/ Recovery Assertive Outreach Service

Community  PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

Community  PRIMARY CARE LIAISON TEAMS Community CONTINUING NEEDS TEAMS;  ASSERTIVE OUTREACH TEAMS  Recovery & Rehabilitation  Teams Community  HOME TREATMENTTEAMS Residential based care: Hospital Beds, Day services, Crisis Homes, Model 1

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes, PRIMARY CARE TEAM Model 2

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE SPECIALIST SERVICES

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE SPECIALIST SERVICES DUAL DIAGNOSIS SERVICE

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE SPECIALIST SERVICES DUAL DIAGNOSIS SERVICE OLDER ADULT SERVICES

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE SPECIALIST SERVICES DUAL DIAGNOSIS SERVICE OLDER ADULT SERVICES CHILDRENS SERVICES

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE SPECIALIST SERVICES DUAL DIAGNOSIS SERVICE OLDER ADULT SERVICES CHILDRENS SERVICES SOCIAL SERVICES

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, NOT the whole picture.. NOT the whole picture.. EARLY INTERVENTION SERVICE SPECIALIST SERVICES DUAL DIAGNOSIS SERVICE OLDER ADULT SERVICES CHILDRENS SERVICES SOCIAL SERVICES ETCETERA!

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

Primary Care Liaison Interface between primary care and specialist service Interface between primary care and specialist service Gateway to specialist services Gateway to specialist services Manage all new referrals from Primary Care Manage all new referrals from Primary Care Key workers with variable case load Key workers with variable case load Clinics, groups, home based intervention Clinics, groups, home based intervention Multidisciplinary team Multidisciplinary team

Primary Care Liaison Working hours service Working hours service Varies across city in terms of delivery because; Varies across city in terms of delivery because; Integration of a continuing needs service: ‘Community Mental Health Teams’ Integration of a continuing needs service: ‘Community Mental Health Teams’ Some Teams have a base with a day hospital-like facility Some Teams have a base with a day hospital-like facility GP’s prefer to provide part of a service themselves e.g. health promotion GP’s prefer to provide part of a service themselves e.g. health promotion Some GP’s commission a service within their surgeries Some GP’s commission a service within their surgeries Different development of Gateway workers Different development of Gateway workers

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

Home Treatment and Crisis Resolution ‘Acute’ psychiatric care at home ‘Acute’ psychiatric care at home Mobile, 24 hour 7 days a week service Mobile, 24 hour 7 days a week service Crisis resolution and Home Treatment Crisis resolution and Home Treatment Access to hospital beds Access to hospital beds Alternative to psychiatric hospitalisation Alternative to psychiatric hospitalisation Multidisciplinary team Multidisciplinary team Shared caseload ≤ 2:1 Shared caseload ≤ 2:1 Utilise home and community resources Utilise home and community resources

Crisis Resolution/ Home Treatment (CR/HT) Rapid response following referral Rapid response following referral Assertive approach to engagement Assertive approach to engagement Intensive intervention and support in the early stages of the crisis Intensive intervention and support in the early stages of the crisis Active involvement of the service user, family and carers Active involvement of the service user, family and carers Time-limited intervention that has sufficient flexibility to respond to differing service user needs Time-limited intervention that has sufficient flexibility to respond to differing service user needs Learning from the crisis Learning from the crisis

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

COMMUNITY MENTAL HEALTH TEAM Primary CareContinuing Need: Liaison Rehab and Recovery CONTINUING NEED ASSERTIVE OUTREACH TEAM HOME TREATMENT TEAM Residential based care: Hospital Beds, Day services, Crisis Homes, PRIMARY CARE TEAM Model 2

Rehabilitation and Recovery (Community Mental Health Teams) People predominantly with ‘severe/ enduring’ illness experience People predominantly with ‘severe/ enduring’ illness experience Complex social and health care needs Complex social and health care needs Long term service use Long term service use Need for community based support Need for community based support Recovery and social integration Recovery and social integration Individual case management but access to team resources Individual case management but access to team resources

 PRIMARY CARE LIAISON Community CONTINUING NEEDS  ASSERTIVE OUTREACH  RECOVERY AND REHABILITATION Community  HOME TREATMENT Residential based care: Hospital Beds, Day services, Crisis Homes, Functional map Functional map

Assertive Outreach Team based approach with key worker Team based approach with key worker Team responsible for meeting all needs Team responsible for meeting all needs Assistance in obtaining basic needs Assistance in obtaining basic needs Primary goal of improved client functioning Primary goal of improved client functioning Assistance with symptom management Assistance with symptom management

Assertive Outreach One team member is care coordinator One team member is care coordinator Smaller case load ( ≤ 15:1) Smaller case load ( ≤ 15:1) Treatment is individualised Treatment is individualised Services provided “out of office” Services provided “out of office” Assertive “can do” approach Assertive “can do” approach

Maintaining a framework Key issues: A system of filters and gateways A system of filters and gateways Fidelity Fidelity Early and later development problems Early and later development problems Staff training Staff training

Fin