NHS Greater Glasgow and Clyde Community Mental Health Team Operational Framework LEAD AUTHOR(S) RESPONSIBLE DIRECTOR Margaret Aitken & Anne Bryce Susanna McCorry-Rice DATE OF APPROVAL 30 th March 2016 APPROVING GROUP CSSR Steering Group DATE FOR REVIEW: 31 st March 2017 VERSION 1.0 KEY TERMS CMHT Easy in Easy Out Stepped Care Refers to adult and older adult community mental health teams (CMHT) and includes all staff working within the CMHT. Patients referred to any part of the mental health services should be supported to access the most appropriate assessment / treatment for them without unnecessary time delays or barriers. Systems should be designed to facilitate timely re-engagement when appropriate following discharge. Stepped care should easily allow the level of care to be stepped up or down within the service or across services according to the persons needs. Supports Matched Care where the level of care provided is applicable to need at any given point in time. Matched Clinical outcomes will be monitored routinely, and efforts made to
Care match patients to the right level of care Patients will be active participants in care decisions and care delivery. Wherever appropriate, non-professional approaches such as peer support or self-help will be used. Intensive Condition Management Combines planning and co-ordination of care with a therapeutic, clinical and supportive role for patients who have complex and frequently changing needs. Week Week(s) referred to in the framework are working week(s) = 5 working days. Change Control Amendment History Version Dates Amendments 2
CONTENTS 1. PRINICPLES VALUES & SERVICE CONTEXT...6 1.1 Introduction, scope and intent...6 1.2 Service Principles...6 1.3 Staff Practice Principles...7 1.4 Confidentiality...7 1.5 Engagement and Participation with Patients and Carers...8 1.6 Person Centred Care...8 2. CAPACITY, CONSENT & SAFEGUARDING...8 2.1 Capacity, Decisions, Advance Statements and Safeguarding...8 3. THE FUNCTION OF CMHTs...9 3.1 CMHT key functions:...10 3.2 Role and responsibilities of team members...10 4. ACCESS & REFFERAL SYSTEM...11 4.1 Eligibility...11 4.2 Processing referrals (including response times)...12 4.3 Role of the Duty Service...13 5. DID NOT ATTENDS (DNAs) AND COULD NOT ATTENDS (CNAs)...14 6. THE PATIENT JOURNEY FOLLOWING REFERRAL...14 6.1 Screening...14 6.2 Before the Assessment...14 6.3 Assessment...14 6.4 Involving families and carers...16 6.5 Assessment Feedback at MDT Meeting / Allocation...16 6.6 Urgent Prescriptions...17 7. INTERFACE WITH SPECIALIST MENTAL HEALTH & OTHER SERVICES...17 7.1 Drug & Alcohol, Learning Disabilities and Specialist MH Service Interface...17 7.2 General Adult / Older Adults / CAMHS Service Interface...18 7.3 Social Work Interface...18 7.4 Interface with Other Related Services...18 8. INTERVENTIONS...18 9. MANAGEMENT OF RISK...19 10. CARE PLANNING...20 3
10.1 Record Keeping...20 11. CO-ORDINATION OF CARE...21 11.1 The scope of co-ordination of care within CMHT...21 11.2 Named Practitioners: Role and Responsibilities...21 11.3 Care Programme Approach...22 11.4 Working in Partnership...22 12. MULTIDISCIPLINARY TEAM REVIEWS (MDT)...22 13. DISCHARGE / TRANSFERS...23 13.1 Transfer- CMHT to Inpatient care and vice versa...24 13.2 Service Interfaces / Transitions...24 14. EQUALITY, RECOVERY AND SOCIAL INCLUSION...24 14.1 Equality...24 14.2 Recovery and Social Inclusion...25 14.3 Supporting recovery and inclusive opportunities...25 15. KEY PERFORMANCE INDICATORS (KPI)...25 15.1 CMHT KPIs...26 16. MANAGEMENT ARRANGEMENTS...26 16.1 Clinical and Operational leadership...26 16.2 Clinical and Line management supervision...26 16.3 Health and Safety...27 17. WORKFORCE...27 17.1 Staffing and Resources...27 17.2 Workload Management...28 18. CONTINUOUS QUALITY IMPROVEMENT...28 Appendix 1: Person Centred Standards of Care...30 Appendix 2: Capacity and Consent...32 Appendix 3: Emerging Best Practice in Recovery... Error! Bookmark not defined. Appendix 4: Did Not Attend / Cancelled Appointments SOP..Error! Bookmark not defined. Appendix 5: Confidentiality and Consent Adapted from Triangle of care.error! Bookmark not defined. 4
Appendix 6: Proposed CMHT KPIs... Error! Bookmark not defined. Appendix 7 Quality Improvement... Error! Bookmark not defined. REFERENCES / RELATED POLICIES / LEGAL FRAMEWORKSError! Bookmark not defined. 5
1. PRINICPLES VALUES & SERVICE CONTEXT 1.1 Introduction, scope and intent The scope of this framework encompasses Adult and Older Adult Community Mental Health Teams (CMHTs), recognising them as the essential linking component of all NHS Greater Glasgow and Clyde (NHSGGC) community mental health services. The intention of this operational framework is to promote a recovery based model of person-centered care that takes into account patients' needs, preferences, strengths i, and which drives consistency of service delivery processes through each NHSGGC CMHT; as well as setting out a framework of key performance measures. The operational framework describes the pathway of care through the CMHTs, covering all aspects of service delivery from the principles, ethos and values base for practice, through to quality assurance and clinical and care governance processes. In applying the framework CMHT staff will exercise clinical judgment and decision making when the framework alone does not provide a straightforward solution to a clinical problem. The Community Mental Health Team (CMHT) forms part of a whole system approach to mental health services for the adult and older adult population of NHSGGC. The service is delivered in conjunction with Primary Care Mental Health Teams (PCMHT); Acute Services (Crisis / Home Treatment Services & out of hours (OOH) Services); specialist Mental Health services and a range of statutory and non-statutory services that support the delivery of care. This operational framework has been subject to Equalities Impact Screening Assessment (EQIA) to ensure that issues with regard to protected characteristics have been fully considered and described within this document. 1.2 Service Principles As outlined in the Service Specification for Mental Health Services in the Community (NHSGGC, 2016) ii, the following key principles will underpin service delivery: Patients will receive appropriate treatment with a minimum of fuss and delay with easy in - easy out access to and discharge from the service. The early and accurate characterisation and understanding of patients problems is critical for an effective system. Quality care depends not only on the overt, measurable aspects of service delivery (medicines prescribed, visits completed), but also on less tangible qualities such as engagement and containment good customer care and meaningful therapeutic relationships. Staff development, satisfaction and fulfilment at work are explicit service goals. 6
Consistent with the 6 quality dimensions; Efficient, Timely, Safe, Person Centred, Effective and Equitable iii, CMHTs will deploy data rich, open systems, able to negotiate and resolve patient expectations and service capability; encourage innovation, creativity and quality improvement in service development; manage inappropriate variation; generalise improvements; learn from mistakes and adapt to changing needs and emerging evidence. CMHTs will provide the minimum effective intervention in a stepped care model. In particular: Clinical outcomes will be monitored routinely using an agreed clinical outcome measure, and efforts made to match patients to the right level of care. Patients will be active participants in care decisions and care delivery. Wherever appropriate, approaches such as peer support or self-help will be used. The system will seek and make use of feedback from patients and carers about their satisfaction with services. Patients and carers will have their needs defined and met with a minimum of transfer around the system and reassessment. CMHTs will prioritise access to the service for armed forces veterans, in line with national policy. This means that armed forces veterans are entitled to priority access to services iv. 1.3 Staff Practice Principles In common with all mental health services delivered within NHSGGC, CMHT staff will adhere to their professional Codes of Practice when exercising any function in relation to the Mental Health (Care and Treatment) (Scotland) Act 2003 v, Adults with Incapacity 2000 (AWI) vi or Adult Support and Protection 2007 (ASP) vii Acts and will have regard to the principles of these Acts. Staff will take into account patients rights to advocacy services as laid out within the Charter of Patients Rights and Responsibilities, with particular reference to the general health care principles within the Patient Rights (Scotland) Act 2011 viii. CMHT staff will practice within a core set of values which are based on a person centered approach to care and service delivery ix and in line with the quality ambitions outlined in the NHS Quality Strategy 2010, Efficient and Effective Community Mental Health Services. In addition, staff will be required to ensure that joint and individual service governance, standards and accountability policies underpin their day to day practice, and be mindful of their role in delivery of equalities sensitive practice. 1.4 Confidentiality The collection and sharing of information is essential to provide safe and effective healthcare. Patients entrust the NHS in Scotland with their personal information, and all 7
staff working within CMHTs have a legal and ethical duty to keep patient information confidential. All staff working in CMHTs will comply with the NHS Scotland Code of Practice on Protecting Patient Confidentiality x, the Data Protection Act (1998) and Caldicott guidance. Information will be managed and shared in accordance with NHSGGC Information Sharing Protocol xi and Mental Welfare Commission Guidance xii 1.5 Engagement and Participation with Patients and Carers The CMHT will work flexibly to engage patients; family and carers in the delivery of services which are user focused and seek to include patient and carer representatives in the planning and review of care plans, offering choice wherever possible. Families and carers include relatives, friends, advocates and significant others who play a supporting role for the person using mental health services. If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need. 1.6 Person Centred Care The CMHT will work as flexibly as possible in the time and location of appointments (home or base), choice of worker, offering second opinions and the overall approach to the individual needs of patients / carers. The views of patients, families and carers are central not only to making decisions affecting their own lives but in more general policy development and monitoring of services and this should be seen as an important function of engaging patients / carers. CMHTs will continue to improve services by listening and responding to concerns, complaints and suggestions and / or queries. Standards for Person Centred Care are included as Appendix1 2. CAPACITY, CONSENT & SAFEGUARDING People who use mental health services should have the opportunity to make informed decisions about their care and treatment, in partnership with their health and social care practitioners. If patients do not have the capacity to make decisions, healthcare professionals should ensure that legal, organisational and professional requirements for obtaining consent to treatment are followed xiii. Appendix 2 provides more detailed guidance for CMHT staff. 2.1 Capacity, Decisions, Advance Statements and Safeguarding CMHT practitioners must ensure that they: Understand and can apply the principles of the: Adults with Incapacity Act 2000(AWI); Adult Support and Protection Act 2007(ASP) and the Criminal Procedures Act 2010 appropriately. 8
Can consider mental capacity and understand how the Mental Health (Care & Treatment) (Scotland) 2003 Act and AWI relate to each other in practice. Inform patients of their right to make an Advance Statement and support them to do so if they wish. Document the Advance Statement (or decision to decline) in their care plans and ensure copies are held by the patient and in primary and secondary care records. Check patients care record for Advance Statements before offering or starting treatment. Consider patients for assessment according to local safeguarding procedures for vulnerable adults. Inform patients of their right to advocacy Consider the safety and wellbeing of any children in the care of a patient according to NHS GGC Mental Health Service; Children Affected by Parental Mental Health Problems - Guidance for Mental Health Staff (2014). 3. THE FUNCTION OF CMHTs CMHTs will aim to work with people with complex mental health problems and associated risks who typically require longer-term care and treatment, multidisciplinary engagement, and with the capacity to provide assertive care and to manage higher levels of risk. Typically CMHTs will work with two broad groups of patients 1. People with conditions that require interventions of weeks or months, with discharge on completion of the intervention. 2. People who require ongoing treatment, care and monitoring for prolonged periods, who should be managed within the recovery model with an expectation of improved functioning which may enable discharge. CMHTs will work in partnership with patients, families and carers, primary care and other agencies to design, implement and oversee comprehensive packages of health and social care where needed, to support people with complex mental health needs. In conjunction with Crisis Teams / Intensive Home Treatment Services, CMHTs will operate a duty system available 7 days per week. The minimum core working hours of CMHTs are Monday to Friday 0900 to 1700. Local flexibility should be a feature of all CMHTs. CMHTs will aim to deliver services in a suitable environment that is accessible to the individual (and their carers). This will include team base, GP surgery, the patients home or other appropriate community setting. Home visits may be appropriate when: The patients physical and social environment is a key part of their health and social care needs assessment. There are concerns about safeguarding and protecting children or adults. 9
An assessment is required of the patients level of functioning in their home environment. Delivering a particular intervention necessitates the patient being at home. Carrying out duties under the Mental Health (Care and Treatment) (Scotland) Act 2003; AWI or ASP Acts. The patient has a significant physical health problem that impairs their mobility. Prior to any home visit being made, a judgement of the risks will be undertaken, taking into account the Lone Working Policy and if necessary a full risk assessment will be completed. 3.1 CMHT key functions: Assessment all accepted newly referred people will have their health and social care needs assessed by the CMHT. Interventions for people with complex and acute mental health needs people who have been assessed as having complex mental health needs are likely to require a range of services and interventions in order to promote recovery and to prevent deterioration, including the provision of specific or tailored treatments, the monitoring of the effectiveness of these treatments and the monitoring and effective management of unwanted side effects. Provide Person Centred Standards of Care as outlined in Appendix 1. Promoting and supporting mental well being and prevention of relapse - raise awareness and promote positive attitudes to mental health issues; Staying Well / Relapse Prevention planning and recovery (see Appendix 3). Support patients to maintain employment CMHTs will support patients and carers to access services while minimising disruption to current employment and will support patients return to employment. Advice, guidance and signposting people who are referred to the CMHT who do not require further intervention to meet their assessed needs may benefit from further information about local / national resources; signposting or onward referral to a more appropriate service, or information about self management of conditions. 3.2 Role and responsibilities of team members CMHTs function using an integrated multi-disciplinary approach whereby all members of the CMHTs will act to: Work in partnership with patients and carers. Reduce the stigma associated with mental health care. Provide assessment, diagnosis and treatment working within relevant Mental 10
Health legislative processes. Focus upon improving the mental and physical well-being of patients. Utilise the experience and knowledge of all team members to help facilitate a holistic approach to patients. Ensure care is delivered in the least restrictive and disruptive manner possible. Stabilise social functioning. Work in collaboration with all agencies involved in providing care. Promote patient recovery, social inclusion and the use of Wellness Recovery Action Planning (WRAP), Staying Well and Relapse Prevention plans where appropriate. Use clinical outcome measures to monitor progress. Ensure patients have appropriate and timely access to self supported, recovery focussed care and assertive approaches according to need. Use clinical outcome measures to monitor patients progress. 4. ACCESS & REFFERAL SYSTEM CMHTs will outline arrangements for access and referral systems in local Standing Operating Procedures (SOP). These SOP will take account of related policies, standards and guidance such as the NHSGGC Psychiatric Emergency Plan (PEP), Access Policy (under development), interface protocols with specialist services (under development) and patient postcode of residence. Patients will be able to access services through referral from their GP or other health and social care professionals. Referrals should be addressed to the CMHT and not individual disciplines. CMHTs will prioritise access to those individuals whose mental health and accompanying social care needs impacts most severely on their ability to function within the community. Consistent with the service principle easy in, easy out patients referred to any part of the mental health services should be supported to access the most appropriate assessment / treatment for them without unnecessary time delays. 4.1 Eligibility Those eligible for a service from CMHTs are individuals aged 18 years and over where there is a concern that the individual may be suffering from a mental illness and the individual has complex needs which require co-ordination of care and / or longer-term treatment. They will include people needing specialist care for: 11
Complex and persistent mental disorders associated with significant disability, for example psychoses such as schizophrenia or bipolar disorder. These patients typically will have long term involvement. Complex problems of management and engagement related to their mental illness. Any mental disorder where there is a risk of self harm or harm to others where the level of support required exceeds that which a primary care mental health team (PCMHT) could offer. Severe disorders of personality where these can be shown to benefit by continued treatment and care. Most patients treated by CMHTs will have disorders which would benefit from time limited interventions and then be referred back to their GPs when their condition has improved. 4.2 Processing referrals (including response times) In order to process the referral, the Team requires accurate clinical information. If this information is insufficient the CMHT will gather further information, in keeping with response times below, prior to any assessment taking place. All referrals accepted for assessment by CMHTs will have a record created (or where a record already exists, continued). All members of the team are responsible for ensuring records are maintained according to professional and organisational standards. CMHTs will aim to achieve positive engagement with people referred, prioritising response depending on level of risk / need under three categories; Emergency (response outlined in PEP), Urgent or Routine. CMHTs will have local SOP specifying actions to be taken if a patient does not attend an appointment arranged within each of the categories. Table 1 below summarises guidance for referrers. Table 1 NHSGGC Mental Health Service guidance for referrers. Category of referral Response time by CMHT Referral method Criteria Emergency Same day Telephone call to duty person followed by supporting SCI gateway referral Presentation with immediate risk of self harm and / or active plans of suicide, acute distress due to psychiatric illness or where someone with a mental health problem requires an immediate assessment. This may include the situation where a patient requires admission to hospital. (Refer to Psychiatric Emergency Plan 2015.) 12
Urgent Within Week (5 working days) SCI gateway As above although immediacy is not present, referrer is satisfied patient is in no immediate danger but requires intervention within the next few days. (Patients discharged from inpatient services to the CMHT will have follow up within 7 days of discharge.) Routine Within 4 weeks SCI gateway N.B. in SCI Gateway Emergency referred to as Urgent 1 and Urgent referred to as Urgent 2 4.3 Role of the Duty Service Each CMHT will provide a Duty service from 9am 5pm Monday to Friday (excluding public holidays). This service will be provided by a named qualified member of staff (Duty Person) within the CMHT who will have access to the Team Lead or Senior Practitioner for advice, support and decision making. The Duty Person is available: For existing clients who cannot reach their lead professional or care co-ordinator. To offer advice and information to other agencies. To discuss and respond to telephone referrals. To screen all referrals for urgency and information. To assess emergency referrals. To review information / communications from out of hours (OOH) services. On a daily basis, to allow timely response to changing risk and consideration of stepped up care, the Duty Person, with access to senior staff when appropriate, will be available to review risk and formulate responses when: There is significant change in the patients circumstances. Known risk triggers are activated. There are safeguarding children and / or adult support and protection issues or concerns. 13
5. DID NOT ATTENDS (DNAs) AND COULD NOT ATTENDS (CNAs) To optimise the likelihood for attendance, CMHTs will: When arranging appointments, consider factors which may inhibit attendance such as communication needs or memory deficits and if appropriate take additional measures to ensure effective communication of the appointment date, time and venue. Offer appointments by phone or by letter, advising patients to contact the CMHT to arrange an alternative date if the appointment is unsuitable or if unable to attend. Send text reminders 3 days prior to the appointment date. Discuss appointment procedures with patients as part of the assessment and ongoing care. Standing operating procedures which are applicable to all CMHTs and which outline the minimum actions to be taken in response to patients who do not attend (DNA) or who cancel appointments are under development and will be listed as Appendix 4. 6. THE PATIENT JOURNEY FOLLOWING REFERRAL 6.1 Screening All referrals will be screened daily and emergency referrals will be dealt with on receipt by the Duty Person. When it is clear from the information on the referral, that an individual s needs would be more appropriately met by an alternative service / team, the referral will be passed by the CMHT to this service and this decision will be communicated to the referrer and the service user. 6.2 Before the Assessment Before assessment, CMHT staff will endeavour to ensure that the patient (and carer) is informed: Of the process of assessment and how long the appointment will last. In relation to confidentiality and data protection as this applies to them. Of the basic approach of shared decision-making. That although they can be accompanied by a family member, carer or advocate for all or part of the time, it is preferable to see the person alone for some of the assessment. That their permission will be sought for any trainees or students to be present. 6.3 Assessment All routine assessments will be commenced within the NHSGGC standard of 4 weeks. 14
A Registered practitioner will undertake an assessment of the individual s presenting mental health and social care needs. The initial information gathered from multiple sources includes: An exploration of the presenting problems. The identification of clinical signs and symptoms, including ability to self-care. The identification of immediate social stressors and social networks, including financial, housing, educational and vocational issues. A risk assessment and management plan in keeping with NHSGGC guidance, which is recorded in the patients care plan. Psychiatric history including past records, family history, childhood trauma and adversity and medications. An investigation of physical health problems: - Current physical health medication, including side effects and compliance with medication regime. - Lifestyle factors e.g. sleeping patterns - diet, smoking, exercise, drug and alcohol use. - Noting of known risk / presence of cardiovascular disease, metabolic disorders, and excessive weight change. An assessment of the patients needs strengths, skills and resources. This includes basic psychological, spiritual, cultural and social needs, level of functioning and communication needs. Identification and recording of the patients primary carer, or lack thereof. Identification of dependants including their wellbeing, needs, and any childcare issues. This includes the names and dates of birth of any children / young people. On completion of the assessment a provisional diagnosis and holistic person-centred formulation including strengths, difficulties and personally defined goals, is recorded in the patients plan of care. CMHTs will ensure that patients with caring responsibilities receive support to access the full range of mental health and social care services, including where possible information about childcare to enable them to attend appointments, groups and therapy sessions as outlined in their plan of care. Unless clinically inappropriate, the outcome of the assessment should be discussed and the plan of care agreed and shared with the patient and their carer (with consent). A copy of the assessment summary and plan of care will be shared with the referrer within 2 weeks following completion of the assessment. In some cases, following assessment, individuals referred to CMHTs are identified who would have their care and treatment more appropriately managed by another service or team. In such instances it is the CMHTs responsibility to avoid duplication in assessment and unnecessary delays for the patients and therefore the CMHT will communicate with the other service to: 15
Expedite the referral to the appropriate service. Ensure the referral is considered / discussed and; Ensure the individual is directed to the appropriate service taking account of clinical presentation / risk and urgency of response required. To support this all relevant documentation will be copied to the service. 6.4 Involving families and carers Consistent with the principles of the Triangle of Care xiv, (see Appendix 5) CMHT staff will discuss with the person using mental health services if and how they want their family or carers to be involved in their care. Such discussions should take place at intervals to take account of any changes in circumstances, and should not happen only once. All decisions and discussions will be recorded in the plan of care. If a patient wants their family or carers to be involved, CMHT staff will facilitate and discuss this involvement between the patient and their family or carers. This will include discussion of: Consent for family or carer involvement. Confidentiality and sharing of information on an ongoing basis. How families or carers can help support the patient and help with treatment, Relapse Prevention / Staying Well and WRAP plans. Ensuring that no services are withdrawn because of the family's or carers' involvement in delivering aspects of care, unless this has been clearly agreed with the patient and their family or carers. Verbal and written information about the mental health problem(s) experienced by the patient and the treatments indicated. Their right to a formal carer's assessment and how to access this. If the patient does not want their family or carers to be involved in their care, consistent with the Triangle of Care guidance, CMHT staff can: Give the family or carer verbal and written general information on mental health problem(s) and the indicated treatments. Give the family or carers information about statutory and third sector / voluntary, local support groups and services specifically for families or carers, and how to access these. Tell the family or carers about their right to a formal carer's assessment and how to access this. Listen to and note family / carer concerns. 6.5 Assessment Feedback at MDT Meeting / Allocation There will be (as a minimum) a weekly Multidisciplinary Team Meeting held which will be supported and led by senior staff members - these will be from medical, psychology, 16
nursing, occupational therapy and social work (Integrated teams). At these meeting formulations from initial assessments, team assessments and assessments requiring multidisciplinary input, will be presented and discussed. If the outcome of the assessment is acceptance into the CMHT service then a key worker / lead professional / named practitioner will be identified to coordinate completion of a plan of care. The assessment and a plan for the delivery of treatment interventions and expected outcomes should be commenced within 4 weeks and completed within 6 weeks of the date of referral. The outcome of the assessment is discussed and the plan of care will be agreed and shared with the patient and their carer (with consent). A copy of the assessment summary will be sent to the referrer within 2 weeks following completion of the assessment. 6.6 Urgent Prescriptions If a patient is assessed as requiring an urgent new prescription or a change of medication, then direct same day communication (e.g. phone call) between the recommending clinician and the patient s GP is required. 7. INTERFACE WITH SPECIALIST MENTAL HEALTH & OTHER SERVICES 7.1 Drug & Alcohol, Learning Disabilities and Specialist MH Service Interface Detailed guidance on interface with all related services and agencies is under development. In the interim, CMHTs will work in partnership with local Drug & Alcohol and Learning Disability services in accordance with local services Shared Protocol for Interface Working. Where clinically indicated referral will be made to Specialist MH services within NHSGGC which include: Forensic CMHTs (including Forensic LD Teams). Adult Autism Service. Adult Eating Disorder Service. Esteem. Psychotherapy. Perinatal Service. Trauma service. Taking account of the Specialist Services Operational Policy, CMHTs will outline referral and transition arrangements with Specialist Services within their local SOPs. 17
7.2 General Adult / Older Adults / CAMHS Service Interface No-one will be excluded from access to any service on the basis of chronological age alone. New referrals to CMHTs services may not always include sufficient information to judge whether the patient is best assessed by adult or by older adult services. Further guidance as to how this situation should be managed is under development. In the interim, clinical judgement should be exercised in this regard. Graduate transitions between Older Adult and general Adult services will continue to be defined by needs, rather than age. Young people who present with mental health problems up to the age of 18 years will come to the attention of Children and Adolescent Mental Health services (CAMHS), in the first instance and can thereafter transfer to adult services as part of a planned transition if clinically appropriate to continue treatment in Adult services. 7.3 Social Work Interface All CMHTs will have local SOP outlining the interface with Social Work services including Area Social Work teams, Adult Support and Protection and Mental Health Officer Services. All CMHTs will have access to their local HSCP Health Improvement Directory, which will support onward referral to services such as money advice, employability and other social support services. 7.4 Interface with Other Related Services Detailed guidance is under development on interfaces with: Accident & Emergency Departments (for repeat attenders). Police Custody Services. Prison Healthcare Services. 8. INTERVENTIONS The CMHT operates as part of a whole system of care. Where a person receives an intervention will be dependent on the level of complexity, the skill mix available within the team and supervision arrangements. Interventions delivered by the CMHTs will be on a stepped / matched care basis, based on individualised assessment of need, and will be governed by the principle of the delivery of the minimum effective level of intervention. CMHTs as a minimum will provide: Full assessment of health and social care needs. 18
Diagnosis including possible alternative explanations for an individual s difficulties. Formulation of a plan of care and interventions / treatments. Risk assessment and formulation of a risk management plan. Evidence based interventions aimed at promoting well-being, independent living, recovery and relapse prevention. Evidenced based psychological therapies and interventions. Medications management including physical health care where appropriate as per NHSGGC Policy xv. Signposting and advice / guidance. Support with Activities of daily functioning. Family and carer support. Help in accessing local opportunities in work, recreation and education. Identification of interventions related to specific Condition Pathways is under development. The duration of treatment delivered will be in keeping with clinical guidelines, and can be delivered in groups or on a 1:1 basis. However, treatment delivery should be implemented flexibly in response to individual patient needs. 9. MANAGEMENT OF RISK A system wide Risk Management Policy is under development, and this section of the CMHT framework outlines the minimum actions to be taken until the implementation of the Risk Management Policy. The assessment and management of risk is an integral part of the screening and assessment processes and is an on-going process with constant consideration to Adult Support and Protection and Child Protection. All patients will have a current completed risk assessment and associated risk management plan. Risk assessments and management plans will automatically be reviewed at MDT Reviews (the frequency of MDT reviews will be outlined in the risk management plan and will occur as a minimum annually). Out with these times risk assessments will be updated at points of transition and if there is an alteration or change to the patients presentation or their management / treatment plan. All information relating to risk assessment and risk management plans will be recorded in the patients health records and on the electronic IT system. While complying with policy, information relating to the patients risk assessment and management plan will be communicated in a timely, concise and effective manner to all those concerned in providing care, including external agencies where appropriate. 19
10. CARE PLANNING All patients and carers (where appropriate) will be involved in the formulation of their plan of care. Care plans will be formulated and agreed using a strength based and recovery focused approach to care delivery which optimises the patients' ability to self manage. Patients will be asked to agree their care plan and this will be recorded in the care plan. Where the patient disagrees, lacks capacity or does not wish to proceed with the care plan, this will be recorded within the care plan along with an outline of actions to be taken. The CMHT will keep GPs and other members of the multidisciplinary / multi-agency team(s) informed of any changes to an individual s care plan. This will occur as an update on progress or following an annual review if there are no changes to the plan. Changes to medications will be managed in accordance with the guidance on the supply of medicines following specialist service review or clinic appointments xvi. This guidance specifies: if a patient is assessed as requiring an urgent new prescription or a change of medication, then direct same day communication (e.g. phone call) between the recommending clinician and the patient s GP is required. At the annual review, the care plan will identify met and unmet need. 10.1 Record Keeping All patients should be registered on PIMS / EMISWeb. CMHTs must comply with the PIMS / EMISWeb and other systems data recording standards and NHSGGC Information Policies as outlined in the Information Governance Framework xvii. All written records must adhere to the Health / Local Authority recording policies and be in accordance with professional standards to provide an objective overview of all contacts and actions relating to the individual patient. All records, paper or electronic are treated as confidential documents. Information is only shared on a need to know basis with the patients permission and under the scrutiny of the Caldicott principles, and in accordance with NHSGGC Information Sharing Policy unless the situation meets necessary risk requirements which would require those rights to be breached. An entry will be made in the clinical record for each contact. This record will include details on the intervention delivered, be signed, dated and include details of the practitioner s job title and team. This entry will also include details of the next planned session, where this is applicable. Formal communication with GPs / referrers will be at the point of assessment (including DNA), discharge and at other relevant points. 20
11. CO-ORDINATION OF CARE Co-ordination of care is a key to delivering better outcomes for patients through better integrated mental health services. It should: Empower people who use services by giving them greater choice in how their support and care are tailored to meet their needs. Ensure greater continuity and speedier delivery of care. Ensure services reach key decisions and determine service outcomes quickly and effectively. Shape the development of more integrated and more responsive services, with better results for people who use them. Support patients in the application of self-directed support. 11.1 The scope of co-ordination of care within CMHT Within the CMHT, co-ordination of care is relevant only for those individuals with complex, rapidly changing or unstable needs, who may require a range of co-ordinated services and is available for as long as is necessary to support people who are the most vulnerable or dependent, in terms of their mental health and community care needs. The key function of co-ordination of care within the CMHT is to have a named practitioner tailor services to meet individual needs; and to co-ordinate the range of services and interventions required to support the individual and their carer, within the community. In doing so the CMHT aims to: Target co-ordination of care for those with complex unstable needs. Prevent duplication, omission and confusion for the patients, their family / carers and referrers. Provide individualised carefully co-ordinated plans of care Where applicable support patients to consider and make use of Self Directed Support (SDS). Self-directed Support allows people, their carers and their families to make informed choices on what their support looks like and how it is delivered, making it possible to meet agreed personal outcomes. Ensure timely and seamless step up or step down care within the team and within integrated mental health services. 11.2 Named Practitioners: Role and Responsibilities Co-ordination of care will be characterised as intensive condition management, and will be undertaken by a range of professionally qualified staff in health and social work. The designated co-ordinator of care (named practitioner) combines planning and co-ordination of care with a therapeutic, clinical and supportive role for patients who have complex and frequently changing needs. During periods of leave which may cause disruption to service delivery when the coordinator of care / named practitioner is not available, the team leader will ensure 21
allocation of case load to other professionals. This will be communicated to the patient and where appropriate the carer. Where the patient is seen by a single professional e.g. Psychology or Psychiatric Out Patient clinic, arrangements for cover during periods of sick leave should be discussed and arranged with colleagues from the same discipline. 11.3 Care Programme Approach For some patients, care will be arranged and managed through the specific guidance and standards as outlined in the Care Programme Approach (CPA). 11.4 Working in Partnership Medical advice and information to GPs and Primary Care staff is made available. Partnership working is actively promoted within the CMHT as a mechanism for improving health and social care outcomes for patients. Partners may include: Patients, families and carers. CPA coordinators. Primary care workers. Other local authority staff. Police Scotland and Probation Services. Voluntary and third sector organisations and community groups. Housing associations. Liaison teams. Link workers. Accident and Emergency Departments Scottish Ambulance Service British Transport Police When patients are assessed as having a dual diagnosis (predominantly mental illness combined with a learning disability, physical disability or misuse of substances) the CMHT will work in partnership with colleagues in other specialist teams. CMHTs will work in conjunction with other professionals and agencies to provide education and guidance about mental health issues. 12. MULTIDISCIPLINARY TEAM REVIEWS (MDT) There will be regular MDT review meetings (at least weekly), at which all known cases with multidisciplinary input will be scheduled for review and complex cases and untoward events discussed. All patients will be formally reviewed within 3 months of allocation to the 22
CMHT and at least annually thereafter. Representations at reviews will be appropriate to the complexity of the case and the patients care plan. Complex case reviews will be undertaken as appropriate. All meetings will be chaired by a senior member of staff. The named practitioner (coordinator of care) / key worker will complete MDT documentation prior to the meeting and will attend and contribute to the MDT review by updating the team on all aspects of care and progress recorded in: Record of care, Risk assessments and plans. Staying Well Plan / Relapse Prevention Plans as appropriate. Crisis management plans as appropriate. Physical health and health promotion. At the MDT review the team will: Review current care plan and consider discharge / transfer or requirement for stepped up / down care. The named practitioner / keyworker will record in the patients notes: actions agreed in relation to the patients care; those persons responsible for completion of the actions; date by which actions are to be completed; how and when actions to be reported back to MDT. A record of the review will be noted in the case record. 13. DISCHARGE / TRANSFERS Consideration and planning for discharge is an integral part of ongoing care planning. Discharge from the CMHT will be arranged following the implementation of a plan of care and following discussion with the patient, and where appropriate carers / other professionals / agencies involved in their care. All patients will have advance notice of an intention to discharge / transfer and be provided with clear information in relation to any future access to services. Prior to discharge it is essential that risk assessments are updated in relation to the Mental Health (Care and Treatment) Act 2003, Adult Support and Protection Act 2007 and Child Protection issues. The outcome of these assessments must be recorded within the integrated health record and shared as appropriate with agencies involved in the patients care. A written discharge summary will be provided to the GP within 2 weeks of discharge. Information to be provided to the patient at discharge will include; A summary of interventions provided. The effectiveness of those interventions. 23
Recommendations for the ongoing or future treatment (including medication). Identified triggers and / or an indication of the early warning signs of future deterioration of the individual s mental health. Arrangements for referral back to CMHT if required. The patients views on discharge. The discharge summary will be filed in the patients health record (and any other relevant IT systems). 13.1 Transfer- CMHT to Inpatient care and vice versa When a patient is admitted for inpatient care the CMHT will continue to have active involvement with the patient and will contribute to plans for discharge. All patients known to CMHTs discharged from inpatient care will be followed up within 7 days of discharge. Local SOP will outline that this may be carried out by a member of the CMHT / Crisis / Intensive Home Treatment Team as appropriate. 13.2 Service Interfaces / Transitions When a patient is moving from one distinct part of the service to another, CMHTs will maintain active involvement with the patient until transition is complete and ensure all relevant communication and documentation is shared. 14. EQUALITY, RECOVERY AND SOCIAL INCLUSION 14.1 Equality The Equality Act 2010 imposes a duty on public bodies to have due regard to the need to eliminate discrimination and to advance equality of opportunity and foster good relations between people who share certain protected characteristics and those who do not. The protected characteristics are age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation. The Act provides an important legal framework which should improve the experience of all mental health patients, particularly those from black and minority ethnic communities. All patients and carers will be provided with information in a manner which is relevant and accessible as part of the individual s engagement with the CMHT service. Formats will include e.g.: Leaflets in plain language. Information in languages other than English. Large print documents. Information on DVD / CD or on audiotape. Interpreter services if required. 24
14.2 Recovery and Social Inclusion People with a mental disorder are among the most excluded in our society. Community Mental Health Services should have a positive and timely response to an individual s illness or disorder. This means that CMHTs have a part to play in promoting opportunities for people who have, or have had a mental illness or personality disorder. These include the opportunity to work, learn, make a home of one s own, engage in leisure pursuits and build friendships. CMHTs will define local arrangements for Recovery Services to support patients. This support may be provided in house by Health and / or Social Care support workers, or be provided as purchased services in partnership with voluntary / 3 rd sector agencies. 14.3 Supporting recovery and inclusive opportunities All aspects of our services should go towards enriching patients lives. Consistent with the principle of stepped or matched care, and as part of a discharge plan, CMHTs should support patients discharge to Recovery Services where time limited support is provided to maintain recovery and support eventual discharge, or if needed, re-entry to the service. In doing so there are a number of agencies and areas that CMHTs need to focus on and engage with, sometimes on behalf of, but mainly in partnership with the patient. CMHTs need to actively review and consider how to address and meet their responsibilities in relation to recovery and social inclusion which will include engagement and support with the following: Housing. Communities. Employment. Personal Finances. Parenting. Education. Lifelong Learning. Volunteering. Arts & Cultural Activities. Healthy Living. Peer Support. 15. KEY PERFORMANCE INDICATORS (KPI) Key Performance Indicators support the monitoring of the performance of the CMHTs across a range of areas. CMHTs will make use of KPIs to ensure that they Can provide evidence of quality and positive patient and carer experience. Provide measurement of change. 25
Provide measurement of variance. Provide efficient and effective services. Undertake benchmarking against other services. The indicators chosen represent high level core aspects of each of the 6 quality dimensions and align with Governmental targets / local delivery plan standards and the following quality statements xviii : 1. People using mental health services, and their families or carers, feel they are treated with empathy, dignity and respect. 2. People using mental health services are actively involved in shared decisionmaking and supported in self-management. 3. People using mental health services feel confident that the views of patients are used to monitor and improve the performance of services. 4. People can access mental health services when they need them. 5. People using mental health services understand the assessment process, their diagnosis and treatment options, and receive emotional support for any sensitive issues. 6. People using mental health services jointly develop a care plan with mental health and social care professionals, and where possible are given a copy with an agreed date to review it. 7. People using mental health services who may be at risk of crisis are offered a crisis plan. 15.1 CMHT KPIs A suite of proposed CMHT specific KPIs is included as Appendix 6; the implementation plan for which is under development. 16. MANAGEMENT ARRANGEMENTS 16.1 Clinical and Operational leadership There is a need for clear clinical and operational lead functions in each team. Clarity of roles and responsibilities in these leadership areas is essential in ensuring the effective functioning of the CMHT. As such, each CMHT will have identified clinical and managerial leadership with these functions being detailed in the local SOP. 16.2 Clinical and Line management supervision The community services manager in collaboration with the clinical and professional leads is responsible for ensuring all staff working within CMHT will have access to, and participate in, clinical and caseload / line management supervision commensurate with the clinical interventions that are being delivered and adhere to Professional, Organisational and Governance policies. 26