NELFT Integrated Adult Care Pathway - Acute and Crisis Care. Asif Bachlani Wellington Makala

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1 NELFT Integrated Adult Care Pathway - Acute and Crisis Care Asif Bachlani Wellington Makala

2 Introductions Dr Asif Bachlani Consultant Psychiatrist B&D Access, Assessment and Brief Intervention Team Associate Medical Director Barking & Dagenham Wellington Makala Deputy Director - Mental Health Inpatient Acute Directorate BME Ambassador

3 RCPsych Acute Commission Report NELFT o Highest ratio of HTT : inpatient care in London o Adult beds: 10 per 100k o OPMH beds: 5 per 100k o No OOA bed since 2008 o SPA - Access Assessment and Brief Intervention Teams

4 Standard Adult Care Pathway Referral HTT Gatekeeper ward SPA CMHT CRT HTT WARD Crisis

5 NELFT Integrated Adult Care Pathway Referral SPA Crisis/Gatekeep SPA CMHT CRT HTT WARD Crisis HTT Alternative to inpt bed

6 NELFT Integrated Adult Care Pathway 1. Developing single point of access 2. Increasing capacity in secondary care 3. Managing demand 4. Managing crisis

7 NELFT Adult Mental Health GP refers Patient Mild Moderate To Severe Talking Therapies Referral to Secondary care Primary Care Psychological Services Access and Assessment including MHS Liaison Stable MH Brief Intervention Team Recurrent/ Chronic MH SMI Cases Medical Interventions Psychological/CBT Groups Psycho-social interventions Education & Employment Community Recovery Teams Home Treatment Teams Acute Inpatient Teams Patient in Crisis (OOH) Mental Health Direct

8 LOCAL CONTEXT

9 Deprivation London boroughs Mental Health budget NELFT 10.9% (London 13.5%, National 12.1%)

10 Population sizes

11 AABIT Referrals & Discharges Referrals Discharges

12 Discharges from AABIT Teams

13 Establishing SPA: Access and Assessment Teams 2010

14 NELFT Adult Mental Health GP refers Patient Mild Moderate To Severe Talking Therapies Referral to Secondary care Primary Care Psychological Services Access and Assessment Stable MH Brief Intervention Team Medical Interventions Psychological/CBT Groups Psycho-social interventions Education & Employment Recurrent/ Chronic MH Community Recovery Teams SMI Cases Home Treatment Teams Acute Inpatient Teams Patient in Crisis (OOH) Mental Health Direct

15 Referrals to Mental Health Services Drivers for Change: o Service Users- Ease of access, and increase demand on services o GPs- Single point of access o Multi disciplinary involvement in assessment, and short term interventions o Consultants-New Ways of Working o Mascalls Park closure and reduction in bed base with Community investment in Havering and B&D

16 Access and Assessment Team Service provides o Full assessment of health and social care needs o Intervention Diagnosis and brief treatment with focus on recovery o Triage and rapid assessment requiring MDT and multiagency assessment o Signposting service to other organisations and groups o Support a step down function to non-mental health primary care

17 Increasing Capacity Recovery Focused Teams 2012

Integrated Adult Mental Health Pathway GP refers Patient Mild Moderate To Severe Talking Therapies Advice and signposting Referral to Secondary care Mental Health Direct 0300 555 1000 Primary Care

18 Integrated Adult Mental Health Pathway GP refers Patient Mild Moderate To Severe Talking Therapies Advice and signposting Referral to Secondary care Mental Health Direct Primary Care Psychological Services Access and Assessment Teams Brief Intervention Team Mild/Mod Cases SEMI Cases Psychological/CBT Groups Psycho-education Education & Employment Depot /Clozapine Clinics Community Recovery Teams Home Treatment Teams Acute Inpatient Teams

19 Moving to the Recovery Approach CMHT o Mild Severe Mental Health Disorders o Outpatient clinic o Too paternalistic o Social isolation o Dependent CRT o SEMI o Patients under CPA only o Recovery Approach o Support recovery, independence, EET o Social integration

20 Brief Intervention Team (CC/BIT) o o o o o o Provide an entry pathway into primary care services by supporting GPs managing mental illnesses Gate-keep referrals to Community Recovery Teams Promote and enable recovery, wellbeing and social inclusion using MDT approach & vol sector Focus on needs and agreed outcomes (BPS) Discharge planning at the point of entry. Short term interventions

21 General Adult caseloads

22 Setting up and implementing Brief Intervention Team (BIT/CC) Guidance to reviewing outpatient clinics o Cases not seen for over a year o Cases open but no activity o Cases who can be discharged within the next 6 months o Cases no longer needs specialist mental health input Brief Intervention Team o Moderate risk and who need more than 6 months intervention o Higher risk to be referred to CRT for CPA level intervention. o Phase 2 to include depot patients and step down from CRT

23 Outpatient clinic numbers

24 Managing Demand Access, Assessment and Brief Intervention 2014

25 AABIT Referrals & Discharges Referrals Discharges

26 GP Referral IAPT Telephone Triage Vol sector Assessment and Treatment Vol CBT DBT Medic MAP IAPT Vol ADHD/ASD CBT Medic CBT ECG Psychosis Non CPA FEP - EIP CPA CRT

27 Access and brief intervention o Assessment o Telephone triaged within 1 day o Urgent cases assessed with 2 days o Routine cases assessed within 6 weeks o Care plan o Bio psychosocial care plans o Use of RAG rating for risk/resource allocation o Short term HCP intervention o Close links to psychological services, SMS and third sector services o Link worker aligned to GP Surgeries

Discharges from AABIT Teams 40 39 35 30 25 22 20 15 14 15 16 16 12 12.

28 Discharges from AABIT Teams

29 Discharges from AABIT Teams

30 Managing Patient in Crisis Access/Mental Health Direct

Cases Brief Intervention Medical Interventions Psychological/CBT Groups Psycho-social interventions Education &

31 Integrated Adult Care Pathway GP refers Patient Mild Moderate To Severe Talking Therapies Referral to Secondary care Primary Care Psychological Services Access and Assessment including MHS Liaison Stable MH Recurrent/ Chronic MH SMI Cases Brief Intervention Medical Interventions Psychological/CBT Groups Psycho-social interventions Education & Employment Community Recovery Teams Home Treatment Teams Acute Inpatient Teams Patient in Crisis (OOH) Mental Health Direct

32 Mental health direct o 24/7 crisis number for patients, carers or referrers to assess o Provides access to crisis support out of hours o Linked to services access during working hours, HTT out of hours

33 ACAT Assessment Team - HTT Acute Crisis Assessment Team (ACAT) the team gate-keeps (assesses the appropriateness) of inpatient admissions o Respond to all new referrals to acute care pathway o Respond to all acute crisis with the integrated mental health pathway o Have overall adult bed management responsibility Our inpatient services: o These aim to provide a high standard of treatment and care in a safe and therapeutic setting for patients in the most acute and vulnerable stage of their illness. o Admissions are considered where this would play a necessary and purposeful part in a person s progress to recovery from the acute stage of their illness.

34 HTT Alternative to inpatient bed o This is a MDT team that operates on a mobile basis 24 hours a day, 7 days a week. Providing treatment at home for those acutely unwell who would otherwise require hospital admission. o offer routine home visits as agreed in the care plan o provide group intervention o Deliver 1:1 sessions by specific disciplines ie, social worker / STR worker / psychologist where the care plan specifies this o Undertake joint visits with other HCPs o Process discharge and signposting o Based on social systems model o Daily review of all acute inpatients wards, facilitation of early discharge

35 HHT Gate keep Admissions Admission HTT hours Review on every Admission MDT Review: Daily Multi-Disciplinary meeting to review assessments and risk profile Daily Options : Discharge Daily Tasks Home Treatment Discharge MHA LD Transfer to PICU Based on risk Or Step Down Options available Home Treatment User/Carer involvement HTT Groups Follow up: HTT Primary care team Ongoing Daily Assessments And Reviews Discharge to HTT or step down if appropriate Review Acute Care Pathway Community Recovery Services Follow up Discharge Pre- Discharge Meeting Involve Community Teams & HTT Sign post to other services

INTEGRATION WITH ACUTE WARDS Starting at 09.

Consultant Psychiatrist ward based (or nominated deputy in brackets) 1 x Ward

staff B6 1 x ward staff B6 (or 5) 1 x ward based OT Pharmacy 1 x Community

36 INTEGRATION WITH ACUTE WARDS Starting at MDT approach The following staff must attend the daily handovers 1 x Consultant Psychiatrist ward based (or nominated deputy in brackets) 1 x Ward SHO 1 x HTT Lead Band 8 ( or 7) 1 x Ward Lead B 7 ( or 6) Daily Meeting 1 x HTT staff B6 1 x ward staff B6 (or 5) 1 x ward based OT Pharmacy 1 x Community Recovery Team lead representative for all borough teams Psychology minimum weekly HTT Medic - minimum weekly Housing rep - minimum weekly

37 INTERFACE WITH COMMUNITY o Weekly review meetings with respective HTT s (during respective handover meetings) o HTT and Ward link person to attend zoning meeting fortnightly o CRS rep attend HTT handover once a week o Care co-ordinators to attend ward review to discuss own clients at least once / week o HTT and Ward link person to attend Access Assessment & Brief Intervention weekly case management meeting o Access Team attends once a week HTT handover meeting

38 Mental health liaison o The team works with all adults over the age of 18 who present to the acute general hospital (Whipps Cross, Queen's and King George's) with mental health difficulties. o The team works with the acute hospital team to ensure that physical health needs are addressed and mental health assessment is carried out in a timely way. o The team works to reduce the length of stay for patients with mental health needs, especially those with dementia

39 Overview of Care Pathway o More investment in community services o Reduction of bed base o Putting People First - Patients managed in the lest restrictive environment o Improved care pathway with primary care o Reduction of CRT caseloads focusing on longterm SMI o Integrated MHS pathway 97% of all our Mental Health patients in the community & 3% inpatient

40 QUESTIONS

Improving Mental Health Services in Bath & North East Somerset

Improving Mental Health Services in Bath & North East Somerset Andy Sylvester Executive Director of Operations Welcome & Introductions Housekeeping Format of the day Presentations Questions and answers