Worcestershire Early Intervention Service Operational Policy Document Type Service Operational Unique Identifier CL-158 Document Purpose To Outline The Operation Of The Early Intervention Service Document Author Tony Gillam, Dr Jo Smith, Dr S Natynczuk, Dr A Farmer Target Audience Other Services, Commissioners and The General Public Responsible Group Adult Mental Health Service Delivery Unit Date Ratified 06.07.2012 Expiry Date 06.07.2015 Date Equality Impact Assessment Completed
Worcestershire Health and Care NHS Trust Worcestershire Early Intervention Service Operational Policy The Early Intervention (EI) Service addresses the needs of young people who have recently experienced a first episode of psychosis and/or bipolar disorder. The service assists individuals and their families to cope with the experience of psychosis/bipolar disorder, promoting optimal recovery and preventing further episodes. The focus is on maintaining and developing community links, and helping individuals to determine their own goals. Bases The service has two bases: The South Worcestershire EI Team are based at 5 Merriman s Hill Road, Worcester, WR3 8AL; The North Worcestershire EI Team are based at New Brook, Princess of Wales Community Hospital, Bromsgrove, B61 0BB. Hours of Operation The service operates on weekdays between 9am and 5pm, with some flexibility as required. Out-of-hours support is provided from existing services. The service works closely with the Crisis Resolution and Home Treatment Teams who provide out-of-hours crisis support for EI service users as required. 1. Team Values 1.1 The service works within a recovery model, maintaining sensitivity to issues of gender, culture, race, spirituality and sexuality. 1.2 Family-sensitive approaches are emphasised, and we will work collaboratively with service users families, friends and carers to ensure the family receive appropriate support. 1.3 Interventions that are appropriate to age and phase of illness are used in a manner that avoids coercion and minimises stigma and trauma wherever possible. 1.4 The service is based on a strong culture of multidisciplinary team-working. 1.5 Team members work in an intensive, proactive manner using the least restrictive options that reflect the needs of young people and support the development of normal social roles and goals. 2 Aims of the Service 2.1 To reduce the duration of untreated illness and prevent, delay or reduce the severity of further episodes; 2.2 To provide to young people, families and friends, information about the condition, coping strategies and medication management; 2.3 To maximise service users control over their experiences and minimise disruption to the lives of the young person and his/her family; Page 1 of 8
2.4 To provide integrated evidence-based management for young people with psychosis/bipolar disorder in partnership with other agencies; 2.5 To provide phase-appropriate medical management 2.6 To provide psychological and psychosocial interventions on an individual, group and family basis and optimise psychological, social, educational and vocational outcomes 2.7 To prevent or reduce the development of secondary problems such as depression, posttraumatic stress disorder, anxiety, motivational difficulties and the risk of longer term physical health problems; 2.8 To reduce the risk of suicide and deliberate self-harm; 2.9 To address co-morbid problems such as substance misuse, physical and learning disabilities; 2.10 To raise community awareness, to educate health and other agencies about psychosis and bipolar disorder and to reduce the stigma surrounding these conditions. 3. Objectives 3.1 To work with primary and secondary care, CAMHS, education, housing, criminal justice and community agencies to improve early detection and pathways to care to reduce treatment delay 3.2 To provide open and direct access for referral to our service for the above (and for helpseeking individuals), and to provide prompt assessment following multi-disciplinary team discussion of appropriateness and urgency 3.3 To use a standardised assessment process and tools to identify needs, monitor progress and to assist in the evaluation of care; 3.4 To offer support in the service user s own home or in alternative, community settings to offset the young person s reluctance to engage with services; and to reduce potential stigma and trauma; 3.5 To maintain early and sustained engagement, by allocating a case manager following acceptance onto caseload. The case manager will usually work with the individual for up to three years and act as care coordinator where the service user is subject to the Care Programme Approach (CPA). Each whole team equivalent case manager will carry a maximum caseload of 15 cases. 3.6 To use phase-specific, evidence-based interventions including relapse prevention strategies, early warning signs monitoring, medication management, psychoeducation and cognitive behavioural therapy. 3.7 To provide family-orientated approaches including Behavioural Family Therapy and carers support / information groups; which actively involve the family in engagement, assessment and treatment, and which help to improve family coping strategies and clinical outcomes for service users; Page 2 of 8
3.8 To address the educational and employment needs of the individual by engaging schools, colleges and employment services, to ensure that the individual can continue in education, gain skills through training and can access mainstream paid or supported employment 3.9 To liaise with and educate other agencies such as the police, A&E, youth services, schools / colleges, housing agencies, benefits agencies etc through formal presentations, joint working, consultation and advice. 3.10 To manage and prescribe appropriate medication as required, minimising the risk of unwanted side effects. 3.11 To actively create community-based opportunities for young people to have fun and enjoy age appropriate social and leisure pursuits. 3.12 To liaise with primary care to address physical health needs and to facilitate an annual health check and reduce the risk of longer term physical health problems 4. Eligibility criteria 4.1 The criteria are derived from the Policy Implementation Guideline (PIG) for Mental Health (DH, 2001), from NICE Guidance on schizophrenia (NICE 2003, 2009) and on bipolar disorder (NICE, 2006) and from good practice established by the Worcestershire Early Intervention Service and other EI services. Service users will be eligible for assessment by the service when they are: aged between 14 and 35yrs (inclusive) and living within the catchment area (or registered with a GP where there is a contract for service provision) and presenting with signs and/or symptoms indicative of emerging psychosis or at high risk of developing a psychosis (i.e. exhibiting attenuated or transient psychotic symptoms lasting less than one week, or having a first degree family history of psychosis with functional decline) In addition: or presenting with a first episode of mania indicative of Bipolar I disorder service users should have had no treatment from mental health services for a previous psychotic illness or bipolar disorder other than screening or assessment Exceptions to the previous treatment rule Service users will be eligible for assessment where they are either or Young people transferring from other Early Intervention in Psychosis Services Young people between the ages of 14-18 years who are seen already and / or are being referred from CAMHS services. Page 3 of 8
.4.2 Individual will be taken onto caseload where definite evidence of a first episode of psychosis or first episode bipolar I disorder is present. EI is targeted at young people who are thought to have a primary or co-morbid diagnosis of functional or affective psychosis. However, the service is orientated to work on the basis of symptoms rather than diagnosis: this usefully enables the team to tackle the question of diagnostic uncertainty endemic to this area of work. Team members are always willing to discuss cases of diagnostic uncertainty with the young person s current care team. Where an individual has a dual diagnosis, the team will focus on treating the psychosis symptoms and will work collaboratively in developing a shared care plan and agreeing who has lead responsibility for care with the team treating other aspects of the young person s comorbid difficulties. 4.3 Where definite symptoms of psychosis are absent but the individual is considered at high risk of psychosis i.e. those service users with a so-called At Risk Mental State (ARMS) - the team may do one or more of the following: Take service users onto caseload provisionally for an extended assessment to follow them up and offer support to aim to prevent transition to full blown first episode psychosis Provide information and advice to the young person, their family and their referrer regarding self-management and signposting on to other resources and services as appropriate. Provide brief time limited interventions. 4.4 Individuals aged 14 16 are assessed in conjunction with CAMHS. Medical responsibility for under-16s remains with CAMHS. The EI Service has a CAMHS/EI Case Manager who works with 14-18 year olds (inclusive). The work of this worker and the arrangements for liaison, communication and clinical responsibility between CAMHS and EI for the under-18s is governed by the Trust s Protocol for the joint management of adolescents (aged 14-16 years and 16-18 years) with first episode psychosis between CAMHS and EIS) and Worcestershire CAMHS AMH Transition Policy (2011).. 5. Catchment Area Those resident or temporarily resident in the catchment area of Worcestershire Health and Care NHS Trust. This includes the localities of Worcester City, Malvern Hills and Wychavon, Wyre Forest, Bromsgrove and Redditch. Where service users move outside the catchment area during their period of care with the service, a decision will be made as to the reasonableness and appropriateness of continuing the contact, based on a risk assessment. If it is deemed impractical, inappropriate or unsafe to continue providing care the team will facilitate a transfer of care to another service or alternative support arrangements. 6. Referrals 6.1 Referrals should be made to the relevant EI Team rather than to individual members of that team. Referrals will be accepted from a wide range of sources including primary and secondary care, CAMHS, education, housing, criminal justice and community agencies. 6.2 Self-referrals and referrals from carers/family members will be considered after consultation with the GP and other relevant professionals. 6.2 Telephone referrals will be accepted provided they are followed up in writing. 6.3 The service is unable to offer an initial crisis response, so usual clinical pathways for urgent, crisis and out-of-hours referrals should be used. Page 4 of 8
6.4 All new referrals will be discussed at the next weekly clinical team meeting, when two workers will be allocated to carry out the assessment (if appropriate) and to liaise with the referrer 6.5 Following assessment the referrer will receive a letter confirming that the referral has been assessed and whether or not the case has been accepted onto caseload. Where cases are not accepted, advice will be given on a range of options for the referrer to pursue. 6.6 Referral details will be logged onto the National Computer Registration System (NCRS) and the EI service s referrals database. 7. Current Team Membership The teams comprise a number of CPN/Case Managers, CPN Prescribers, Clinical Psychologists, a Clinical Manager, Team Secretaries, a CAMHS/EI Case Manager, OT/Case Managers, a Social Worker, Consultant Psychiatrists, a Staff grade Psychiatrist, an Employment Specialist, a Clinical Development Lead and student and trainee health and social care professionals of all disciplines. 8 Team Meetings 8.1 Clinical Meetings are held weekly in both the North and South teams. These meetings are for the allocation of new referrals discussion of the most recent assessments review of any current inpatients, any service users undergoing home treatment and any subject to Community Treatment Orders (CTOs), any service users currently considered to be high-risk, any other concerns about service users and case formulation 8.2 Non-clinical team meetings are held monthly to discuss the non-clinical business of the teams. 8.3 The service holds quarterly study days to maintain cohesion between the North and South EI teams and to promote multidisciplinary continuous professional development. These study days include presentations/formulations of existing cases, sessions on particular topics or skill updates, and can include invited speakers. 8.4 The service also holds occasional awayday meetings for evaluation / research / strategy development and team-building. 9 Supervision 9.1 The Clinical Manager and the CPN Prescribers provide individual clinical supervision and management supervision to case managers (nurses, OTs and Social Workers) on a monthly basis. 9.2 The EI lead psychologist (or a designated deputy) provides individual clinical supervision and management supervision to junior psychology staff (qualified and assistant psychologists) on a fortnightly basis. Page 5 of 8
9.3 EI medical staff make use of existing medical supervision arrangements. 9.4 Supervision in family work is provided by the Trust s Family Work Trainers/Supervisors on a monthly basis. 9.5 Clinical psychologists provide supervision in Cognitive Behavioural Therapy and all clinical staff practising CBT can access this supervision. 9.6 The Clinical Manager, EI Clinical Development Lead and Consultant Psychiatrists access peer and/or external clinical supervision. 10 Accountabilities 10.1 The Clinical Manager is accountable to the Adult Mental Health Service Delivery Unit Community Lead. The Clinical Manager is responsible for service management, and organising and co-ordinating the contribution of staff from within and outside of the two teams, regulating workloads and managing all aspects of day-to-day operation. The Clinical Manager will also carry out some clinical work, as per his/her job description. The Clinical Manager will decide priorities, formulate and revise team plans and objectives, in collaboration with the EI Steering Group (comprising the Consultant Psychiatrists, the CPN Prescribers and the EI Clinical Development Lead). 10.2 All case managers are accountable to the Clinical Manager. 10.3 All psychologists are accountable to the EI Lead Psychologist in conjunction with the Clinical Manager. 10.4 All non-consultant medical staff are accountable as per their job description. 10.5 The EI Clinical Development Lead is accountable to the Adult Mental Health Service Delivery Unit Lead. 10.6 The EI Consultant Psychiatrists are accountable to the Clinical Director. 10.7 All team members will have access to appropriate professional leads for professional issues. 10.8 The team is operationally located within the Adult Mental Health Service Delivery Unit and is governed by Trust and Adult Mental Health Service Delivery Unit planning and governance arrangements. 11 Training 11.1 All team members will have access to the Trust s training department. Service training needs will be determined by the teams and the clinical manager. All team members will have an annual Staff Development Review with their manager. Personal development plans will identify individual training needs. The team is also a member of the West Midlands (South) regional EI network. 12 Evaluation 12.1 The operational policy is reviewed periodically. Page 6 of 8
12.2 The team is required to audit aspects of service and provide data for routine performance management requirements and CQUINS for the Trust, Commissioners, SHA and DH as appropriate 12.3 The team collects routine outcome and satisfaction data including: Recovery Star and PSA16 data on employment, education and accommodation of service users. Service user satisfaction is audited through the CQUIN Patient Experience Survey. Family and carer satisfaction is evaluated through feedback taken at Carers Groups and through written evaluation of family work 12.4 The team contributes to local, regional and national audit and research projects (as capacity allows). 13. Statistics and Recording 13.1 The team maintains records and statistics as per Trust policy. 13.2 Clinical contact data will be recorded on NCRS and/or Framework-I as appropriate 13.3 Clinical notes are kept in accordance with Trust Information Governance policy. 14. Safety and Security The Team adheres to the Trust s Safety and Security policies (i.e. lone-working, out-of-hours, risk management, etc) and to policies relating to safety and security of the team s accommodation. Operational policy history First drafted 23-09-03 First reviewed in Aug 04 (by Tony Gillam, Clinical Manager) Second review July 06 (by Tony Gillam, Clinical Manager) Third review November 07 (by Jo Smith, Sally Natynczuk, Alan Farmer, Tony Gillam) Out for team consultation in February 08 Redrafted June 08 (by Jo Smith, Sally Natynczuk, Alan Farmer, Tony Gillam) Redrafted (by Tony Gillam) and submitted to the Primary Care Mental Health Business Unit s Governance meeting, February 2011 Revised May 2012 by Tony Gillam and EI colleagues and submitted to the Adult Mental Health Service Delivery Unit Quality Meeting for approval Page 7 of 8