1. CRISIS MANAGEMENT AT THE MANAGED CLINICAL NETWORK

2. Aims Outline crisis management ‘framework’ at MCN Highlight contributing factors in developing a shared understanding Outline evaluation project

3. Service Criteria Diagnosis of personality disorder or identified personality difficulties Multiple ‘complex’ needs Significant risk, particularly to self Poor response to previous treatment Limited social network Difficulty maintaining contact with services 18 and above

4. MCN Care Co-ordination Up to 100 weeks clinical case management Small case loads Assertive approach ‘Intensity’ titrated to stage of treatment Safety & Containment Control & Regulation (A Simpson, C Miller & L Bowers, Journal of Psychiatric and mental Health Nursing, 2003)

5. Service User Involvement Accommodation Individual Psychology/ Psychotherapy Group Work Programmes HCSW Support Pharmacy Input Occupational Therapy Care Co-ordinator & Service User 3 rd Sector Parties Inpatient Teams Crisis Resolution home treatment team Family & Carers

6. Key Challenges Significant number of inpatient admissions Significant degree contact CRHT team & police (S136) How to manage ‘splitting’ across services How to embed ‘general therapeutic strategies’ How to balance immediate safety with treatment goals

7. Crisis Management Framework Principle: ‘Relief comes from having a connection with someone who understands’ Goals Support service user to ‘contain’ distress Prevent an escalation Support service user to return to the previous level of functioning as quickly as possible Respond in a way informed by a formulation Avoid a service response which escalates distress or reinforces maladaptive behaviours Therapeutic Stance Align with the patient’s distress ‘Containing’ Interventions Convey support and understanding Establish a connection with the service user Focus on affect rather than content Use straightforward, concrete statements that reflect an understanding of the current situation and the patients’ experience Reinforce the service users strengths and self-management skills Set limits supportively Arrange additional support (e.g. MCN team, CRHT) (Practical Management of Personality Disorder – John Livesley 2003)

8. Crisis Plan Template What might be helpful to know about my past?What is a crisis to me ?Events that can lead to a crisis / triggersWhat can help if I feel like this?What does not help / makes things worse?If I need support, how and where do I get it?Helpful thoughts to keep in mindHow can people help me to use this planWho has contributedEmergency contacts

9. A Shared Approach, What Helps? Crisis plan framework Formulation informed crisis plans Crisis plan developed with service user and key ‘partners’ Guidance for admissions incorporated into CPA care plans Practice development lead role Consultation KUF training ‘Specialist’ services Development of ‘whole systems pathway’

10. WHOLE SYSTEMS PATHWAY Offer immediate containing interventions Service user first point of contact in a potential crisis:- PDCN, CRHT, DSHT, A&E Assess risk - Refer to current FACE risk assessment and CPA crisis management plan Risk remains unacceptably High Try other treatment options: Involve family/carers Increase visits Use alternative community services – Dial House, Connect etc Risk remains unacceptably high Hospital admission Ward interventions should provide safety, structure, consistency and increased contact/input Refer to CPA care plan if appropriate Clinical reviews with Network Coordinator should take place within 48 hours of admission wherever possible What does the service user want: Relief from distress Risk remains unacceptably High Contact CRHT triage Initiate joint assessment whenever possible Home treatment ACS Discharge planning to involve care co-ordinator, ward team and service user

11. Crisis Plan Evaluation Project team; Mike Pearce, Practice Development Lead Vicky Green, Care Co-ordinator Vicky Baldwin, Education & Practice Consultant Jamie Scott, Clinical Team Manager Project Aim To evaluate the impact of the development of collaborative crisis plans between Crisis Resolution Home Treatment (CRHT) & Personality Disorder Clinical Network (PDCN) staff and service users currently engaged in care co-ordination at the PDCN. change in service user’s self assessed capacity to manage ‘crisis’ effectively change in service user’s experience of PDCN & CRHT teams in responding to ‘crisis’ change in staff’s self –assessed knowledge, attitudes and skills change in amount and type of contact with ‘out of hours’ services Inclusion criteria All service users engaged in the care co-ordination intervention (September 2011) (sample size 20)

12. Process Produce Evaluation Report Collect comparative service use data (September 2012) Post crisis plan questionnaire (September 2012) Crisis plan review meetings Crisis plan completed with care co-ordinator and a member of the CRHT team (October 2011) Pre evaluation period questionnaire (September 2011)

13. ‘When written in Chinese, the word CRISIS composed of two characters, one represents danger, the other opportunity’ John F Kennedy Any Questions?