1. Best Practice When Engaging Hospitals & Community Mental Health Teams
Sophie Koehne and Steffan Desscan
Advanced Mental Health Practitioners
KHP Pathway Homeless Team - SLaM

2. Outline Mental Health and Homelessness
Difficulties Accessing MH Services
4 Levels of Mental Health Care
Points of Access to services
Onward Referrals
Working with Mental Health Services
KHP Pathway Homeless Team Model

3. Complex Health needs & Tri-morbidity
Mental Health
Substance Misuse
> 60% history of substance misuse
70% reach criteria for personality disorder
4-5 times high rates of psychosis than housed population
Physical Health
>80% at least 1 health problem,
20% have more than 3 health problems

4. Homelessness Mental Health

5. Difficulties with accessing mental health services
Knowing where to start
Getting an assessment
Lack of early intervention before crisis point
Knowing when to access A&E
What are your rights and duties as carers
Lack of holistic approaches
Lack of understanding of MH and Homelessness
Not knowing the full history
Busy/hurried clinicians
MH Gatekeeping
Knowing what to expect

6. 4 Levels of Mental Health Care
Hospital Admission
Crisis Resolution Home Treatment Team (CRHTT)
Community Mental Health Team (CMHT)
General Practitioner (GP)

7. Points of access GP Non-urgent/Routine
Main point of access to MH Services
A&E
In Crisis
Out of hours emergency
Police
Causing a risk to themselves or others in a public place

8. Onward Referrals Needs specialist input CMHT GP IN CRISIS HTT/ CRT A&E
Hospital Admission
Police
Place of Safety (s136)

9. Onward Referrals CMHT GP Low MH Risk Minimal MH risk HTT/ CRT
A&E
Medium MH Risk
High MH Risk
Hospital Admission
Police
Place of Safety (s136)

10. Onward Referrals CMHT Minimal MH Risk GP Low MH Risk HTT/ CRT A&E
Medium MH Risk
Physical Health risk
Important to note that most of our referrals are not rough sleepers
Outside of central London – hidden homeless and sofa surfers not picked up by traditional collection methodologies
Hospital Admission
Police
Place of Safety (s136)
High MH
Risk
Chaotic/Violent

11. Onward Referrals CMHT GP HTT/ CRT A&E Hospital Admission
Police
Place of Safety (s136)

12. What you can do to aid access to services
Know your local services
Have a list of contacts – build a database
Support clients to attend appointments at GP / A&E
Write a letter outlining concerns to GP or CMHT
Knowing your client’s story…

13. What you can do to aid access to services
Knowing your client’s story:
What’s brought the client (and you) here (presenting issue)?
How has their behaviour changed (symptoms)?
How long have you noticed changes in behaviour (recent history)?
Has this happened before (history)?
What is normal behaviour for client (baseline)?
What’s caused this change (triggers/stresses)?
What’s worked well in the past (coping strategies)?
What are your concerns if left without specialist support (risks)?
Who is in their support network?
What do you think they need (care plan)?

14. Working with Services Personalised Collaborative Care Plans
Risk – shared management
Holistic care - discuss strengths and goals
Know what can and can’t be communicated with and without consent (confidentiality)
Attend ward rounds/CPA (care planning meetings) with your clients to be involved in times of transfer of care
Regular communication with services involved with clients
Know your duties and limitations as carers
Manage your (and clients) expectations!

15. KHP Pathway Homeless Team Model
Prevent the revolving door
Improve hospital experience
Reduce unsafe discharges
Improve health and housing outcomes
Support to access scheduled care
Reduce bed days
Reduce readmission to hospital
Promote Inclusion Health approach

16. Multidisciplinary Approach
Team focus on case formulation and action planning
GP- Holistic clinical review, advise support admitting team.
Housing Worker - specialist housing knowledge, rotations, advocacy at housing, knowledge of services
Advanced MHP – backgrounds of working with patients with complex mental health issues, knowledge of mental health services and formulation of plan for how the team will work with that patient and manage risk
Notes – receive a referral comprehensive notes review and background check prior to assessment.
Team discussion on referral, how best to proceed, what patient’s needs are, best placed person to assess – process led by Advanced MHP’s
Team highlight any physical health issues and liaise with GP – holistic health screening, liaison with admitting team regarding health needs
Each case will have input from entire team. Each case is discussed on a regular basis and how the team works and liaison with wards and services carefully planned.
Housing Worker will advise on potential housing options, liaison with homelessness services. When preparing a housing case - summary of needs prepared by MHP’s, supporting letter from GP. Housing Worker’s rotate between sites, each have different background and experience in working with homeless people and knowledge of housing law
Provide advocacy and support at Housing appointments with clients. Sometimes housing worker and MHP will attend assessments with patients depending on their needs.
The MHP role in team important in overseeing and planning the day to day running of the team, leading on complex cases and liaising with community teams.the team is an inpatient service but main focus is on the needs of the patient upon discharge. MHP identify areas of support – referrals needed.

17. Multidisciplinary Approach
Flexible approach – Bridging the Gap
Interventions as an inpatient
Specialist knowledge and networks to support in patient wards
Support post discharge
Handover and support to community teams and services
What that means for the patients
Flexible working approach
Team work with patients who do not have care coordinator when admitted
Patient may not have met their community team prior to being discharged.
Support Wards around referral to appropriate community team.
Follow up with patients in community, handover to care coordinators.

18. Interventions Care Coordinator Advice Staff Training
Holistic Needs Assessment
&
Risk Assessment
Liaison with Services
Reconnection
Housing support
Community health follow up
Practical assistance
GP review & liaison
Staff Training
Advocacy
Challenging practice
Care Coordinator Advice
Information gathering
Frequent Attender Work
Identifying ‘missing’ persons
Community Access

19. Services we work with Wards Reablement Team (Southwark) START Team
Southwark Law Centre 
Bed management meetings
Local authority Housing Departments 
St Mungos, The Passage, St Giles 
GP surgeries 
Street Outreach teams
Hostels
Place of Safety
Non-local authority housing providers 
CMHTs
Health Inclusion Team (HIT) 
No Recourse Teams
Hospital Social Work teams (Lambeth & Lewisham)
KHP Teams at Kings and GSTT 
Routes Home 
Night Shelters
Home Office / Immigration services / Embassies
Welfare teams – for benefits advice and support
Department of Work and Pensions
Police –Probation
OT department
Solicitors
Homeless Day centres
HIV Liaison Team
Other Mental Health Trusts 
Wellbeing Hubs
Solidarity in a Crisis 
Interpreter services
Food banks

20. What we achieved Outcome No. (from 237 caseworked)
Spreadsheet data: 465 referrals and 237 seen and caseworked by team between Feb 2015-Dec 2017:
Outcome
No. (from 237 caseworked)
Improved Housing status
171(72%)
Eviction/housing loss prevented
25 (11%)
Local Authority ‘homeless application’
57 (24%)
Referral to supported accommodation
67 (28%)
Reconnection offered (nationally or internationally)
61 (30%)
No Recourse to Public Funds
24%
Local connection - This indicates a high level of transience and historic GP connection as well as the importance of identifying patients who can be reconnected outside of the SLaM boroughs
Patients admitted to SLaM based on GP, however GP does not always correlate to housing connection
Audit early on in service showed high levels of HIV, younger population. Medical comorbidity

21. Summary
Mental Health is complicated. Mental Health services are even more complicated!
Being homeless or socially excluded adds further complexity!
Real role for homelessness professionals to advocate and educate for our client group
Multidisciplinary and multi-agency working is vital to support the needs of this client group

22. Multi-agency and Multidisciplinary

23. Any Questions??? Sophie Koehne – sophie.koehne@slam.nhs.uk
Steffan Desscan –