North Gwent Crisis Resolution & Home Treatment Team Operational Policy

North Gwent Crisis Resolution & Home Treatment Team Operational Policy

Mission Statement The purpose of the Crisis Resolution & Home Treatment Team (CRHTT) is to provide emergency assessment and intervention for those members of the North Gwent population who are experiencing an acute Mental Health Crisis. The CRHTT will provide information, support and treatment in the least restrictive setting for those who would otherwise be admitted to Talygarn / Carn y Cefn units and ensure that all service users are assessed for an alternative to Inpatient care, we recognise that there are occasions where admission is necessary (Positive factor in an individuals care) The CRHTT believes that each individual has the necessary strengths to overcome such a crisis should they be given the opportunity. We will work in collaboration with the service user, their family and others within their social and professional support network in order to encourage all involved to Learn from the Crisis. The CRHTT will also work alongside the CMHTs to provide intensive Relapse Prevention Work with the aim of preventing crisis situations and promoting recovery.

1. Aims and Objectives 1.1. The CRHTT will provide safe and effective community based assessment and intensive treatment in the least restrictive setting, as an alternative to Inpatient care. 1.2. The CRHTT will coordinate and arrange emergency assessments of those within the community who are felt by primary care to be at imminent risk of admission to hospital. 1.3. The CRHTT will work in conjunction with the CMHT to provide a range of intensive interventions for known service users who are in psychiatric crisis and at risk of further deterioration and subsequent admission to hospital. 1.4. The CRHTT will "gate keep" admissions of North Gwent Service users to Inpatient services, between the hours 9am and 9pm, ensuring that hospitalisation as an intervention is offered appropriately and uniformly. 1.5. The CRHTT will provide assessment to all service users admitted to Inpatient services outside CRHTT hours within 24 hours. 1.6. The CRHTT will work in partnership with service users, their carers and when appropriate others in their social network, to provide a genuine alternative to hospitalisation.

2. Inclusion criteria 2.1. The CRHTT will target working age adults with a GP within the designated catchment area of North Gwent which is determined by the GP services attached to the North Gwent CMHTs (Torfaen, Blaenau Gwent and North Monmouthshire). 2.2. The core age group of service users will be 18-65, although in line with local guidelines provision can be made for those over 65 years who are currently known to adult services who reside within the GP catchment areas. 2.3. There is currently no formal agreement for the CRHTT to provide a service to service users who fall under the older adult services. This may be a future area for service development. Any service user under the age of 18 should be referred instead to CAMHS services. 2.4. The CRHTT will be a needs led service and will work with those service users who find themselves experiencing an acute mental health crisis which would otherwise result in admission to an Inpatient facility. 2.5. The absence of a permanent address within North Gwent is not necessarily an obstacle to engagement with Crisis Resolution & Home Treatment. 2.6. Assessment and home treatment can be offered to any service user resident in the North Gwent catchment area who would usually reside in another CRHTT catchment, subject to individual discussion and close collaboration with other CRHTTs in the best interests of the patient. If the service user requires admission or any other secondary service, this will ordinarily be provided by their own CRHTT.

3. Hours of Operation 3.1. The CRHTT will provide a service between the hours of 9am and 9pm, 365 days a year. 3.2. The CRHTT will review and amend these operational hours in order to best meet the needs of the service and to accommodate the capacity restrictions of the Team. 4. Accessibility 4.1. The CRHTT will have a primary base at Talygarn. The CRHTT can be contacted at the Team Base on 01495 768727. There is no facility to leave messages. 4.2. In the event of the shift co-ordinator leaving the team base, they can be contacted via shift co-ordinator mobile phone number. 4.3. Outside of CRHTT hours the point of contact is Talygarn Ward on 01495 765700. 5. Staffing /Skill mix 5.1. The CRHTT is a multi disciplinary, multi agency Team; it is made up as follows: 1 x Band 7 - Clinical Team Leader. 11 x Band 6 - Senior Home Treatment Workers (RMN) 4 x Band 3 - Support workers 1 x Band 3 - Team Administrator All will have background experience in acute mental health work. 5.2. All CRHTT Workers will be required to maintain their professional registration through appropriate training or experience, as dictated by their professional bodies.

6. Shift co-coordinator 6.1. Both the early and late shift will have a designated Shift Coordinator who will be the point of contact for urgent enquiries to the team. They will be responsible for coordination of assessments by the Team and by medical colleagues as necessary. 6.2. The shift coordinator will be responsible for the allocation of work at the beginning of each shift and will ensure the outstanding duties are communicated to CRHTT colleagues as necessary. This should include any actions outstanding on the Team handover document. 6.3. The shift coordinator will carry the CRHTT Team mobile phone in order to ensure the team is accessible at all times. 6.4. The AM shift coordinator will liaise with the Inpatient nursing team on Talygarn / Carn y Cefn units each morning to ensure that overnight admissions are reviewed for assessment the following day. 6.5. The PM shift coordinator will, at the end of the day, handover relevant issues and the daily caseload update to the Inpatient team on Talygarn and a printed copy of the handover will be supplied if required. 7. Medical Support 7.1. The CMHT consultant or designated consultant retains medical responsibility for care of their service users while they are on the CRHTT caseload, responsibility may be delegated to a specific consultant. 7.2. Out of hours medical support for the CRHTT will be provided by the on call SHO as identified by the rotas. 7.3. Senior medics will review all service users prior to discharge from CRHTT.

8. Referrals 8.1. Referrals are received directly from: Psychiatric Liaison Duty Desk (Via GP) CMHT OOH SHO / Liaison Emergency Duty Team (EDT) AMHP s Self referrals for relevant service users under Part 3 of the Mental Health Measures, consideration to be given to family members / carers. All mental health act assessments including 136 assessments, good practice suggests that these assessments should be discussed with HTT. 8.2. Referrals received from the CMHT for known service users will be accompanied by an up to date risk assessment, and CTP Assessment. 8.3. Referrals are not routinely accepted from the Police in the same manner as any Secondary service, however if the service user is known and agreeable, each case will be discussed on an individual basis. 8.4. In the event that there is reasonable doubt as to the appropriateness of a referral to CRHTT it will considered best practice for the team to offer assessment and to follow up these concerns with the team leader and with the referrer. 9. Out of hours referrals 9.1. Requests for out of hour s referrals from Primary Care will be screened by the on-call junior doctor on the rota. These requests will be discussed with the CRHTT and an appropriate assessment plan will be agreed. 9.2. In North Gwent, GPs tend to call the CRHTT directly out of hours to request assessment. These will only be triaged to the SHO if CRHTT has no capacity.

10. Gatekeeping 10.1. AQF Target13 (Gatekeeping/24 hour follow-up) - For the purpose of the AQF Target Data gathering the following descriptive will be used in identifying the target population eligible for and what constitutes Gatekeeping/24 hour follow-up assessments. 10.2. Target Population - The HTT s will provide a gatekeeping/24 hour follow-up function for those admissions that would be provided a service by their locality Community Mental Health Team The population should include: Admissions of sector service users to other units e.g. due to lack of available local beds Admissions to PICU Admissions of NFA patients (as defined by Health Board policy i.e. those who are not registered with locality GP) The population should exclude: Admissions of out of sector service users i.e. those who are admitted in order to support other inpatient services with difficult to manage situations/bed crises. Service users admitted to provide specialist intervention outside remit of adult services eg Detox, CAMHS inpatient stay. All admissions direct from Court/Prison. 10.3. Gatekeeping Assessment - is a face to face contact between service user and an assessment team consisting of at least one HHT clinician with a view to identifying positive risk management strategies and hence provide alternative to admission. Gate-keeping assessment should be undertaken for all service users who are felt to be likely candidates for admission e.g. MHA assessments, known service users who are considered to be relapsing. To ensure that the service user pathway is not unnecessarily delayed an individual will be deemed as Gatekept if the HHT cannot provide reasonable safe alternative interventions, this will include: All admissions for Clozaril Therapy. All admissions for Electro Convulsive Therapy (ECT). All admissions of Assertive Outreach service users. Section Admissions where additional clinicians at assessment would cause unnecessary distress to service user.

These admissions will only be deemed Gatekept following an in-depth case discussion with the HTT to confirm risks, acuity and the potential for facilitating an earlier discharge. 10.4. Follow-Up Assessment (24 Hour) - is said to have taken place once the HTT has reviewed admission notes and assessed the service user face to face (ideally jointly with Inpatient Team) This interview should only be deferred if it is considered unsafe to undertake, but in this case the possibility of Home Treatment would have been considered. 11. Assessment 11.1. Assessments are undertaken by two clinicians which could be CRHTT Workers or jointly with Care Co-ordinator. Assessments are offered at services users home or at health care setting. 11.2. The CRHTT aims to provide an assessment within 4 hours of receiving a referral requiring crisis intervention but this may exceed that time after negotiations with the service user to best meet their needs. 11.3. The CRHTT will use the Health Board and Local Authority agreed CTP Assessment documentation. This will be recorded electronically on the epex by admin support. 11.4. WARRN (Welsh Applied Risk Research Network) Risk Assessment Tool will be undertaken on all service users as per Health Board guidelines and typed directly onto epex. 11.5. The CRHTT will actively seek consent from the service user to share information and document this consent as appropriate during initial assessment.

12. Assessment Outcome: 12.1. Assessment by the CRHTT will result in either: Home Treatment episode Referral back to initial referring agent with reasons why Inpatient admission, possibly followed by Early Discharge after a period of stability. 12.2. If Home Treatment is appropriate and the service user is presently known to psychiatric services, the CRHTT will arrange a joint visit with the care coordinator at the earliest convenient opportunity. This is not just to plan discharge but also to maintain continuity of care for the service user. 12.3. Should the referrer not be present at the initial assessment the CRHTT will inform them of the outcome as soon as possible, and a summary of the initial assessment will be forwarded to them by fax / post. 12.4. Should Home Treatment be inappropriate or declined, the CRHTT will advise the service user and referrer of any available alternatives. Consideration should be given to the service user s capacity to decline the intervention of CRHTT and to their ongoing safety. 12.5. In the event that Home Treatment is not possible as a result of a lack of capacity on the part of the CRHTT to provide a care plan, the likelihood is that the service user will be offered admission to hospital. This will be closely monitored and recorded via the CTP Unmet Needs Process.

13. Home Treatment 13.1. The service user and significant others in their social network will be encouraged to be involved in planning Home Treatment interventions. 13.2. Initial care planning will focus on maintaining the safety of all over the first 72 hours, and all involved with the planning process will be given information about the CRHTT and how to contact services during the crisis episode, with crisis care plans being reviewed on a weekly basis. 13.3. The CRHTT will support service users through regular contact in person and by telephone. This will be planned to reduce as needs diminish. The CRHTT will plan to discharge service users within 6 weeks, and will involve both service user and the CMHT in discharge planning as soon as is appropriate. 13.4. Interventions will include: Support and liaison with social care issues Medication management monitoring mental state ongoing risk assessment Psychosocial problem solving Advice and support to carers Psychoeducation 14. Medication 14.1. The CRHTT will monitor and administer medication in line with Nursing and Midwifery Council guidelines. 14.2. Medication to be given to a service user can be obtained by the CRHTT after prescription by the medical team via a community prescription (FP10). 14.3. The CRHTT holds a small stock of medication on Talygarn / Carn y Cefn for short term emergency use, as per ABHB Storage / administration of medication policy.

15. Lone worker/risk management 15.1. Members of the CRHTT will work in line with principles set out in the Health Boards Lone Workers Policy. 15.2. Each Team member will record their whereabouts at all times as they enter and leave the Team base on the in/out board. 15.3. Each Team member will report in as safe with the shift coordinator at the end of their allocated shift. 15.4. Personal details of each Team member will be held in a file in the CRHTT office for use in case of emergency. 15.5. CRHTT workers should always carry their work mobile phones whilst on shift. 16. CTP 16.1. The CTP care coordinator role for known service users will remain within the sector CMHT. Where service users are known to the CMHT, their care coordinator retains responsibility for CTP care planning. 16.2. For service users who are not previously known to secondary care, following an assessment period of up to 14 days (as per CTP Board agreement) the CRHTT will confirm if they are a relevant patient under the Mental Health Measure (Wales) 2010. Named CRHTT clinicians will undertake the role of care coordinators once identified as relevant patient. 16.3. The CRHTT will attend CTP reviews of those presently on the Team caseload, in order to inform the process of crisis planning. 16.4. It is not appropriate for the CRHTT to be identified as part of a routine CTP crisis plan, without prior consultation with the Team. The CRHTT is not a service that should be prescribed or promised to a service user without involvement of the CRHTT.

17. Review and supervision 17.1. Ongoing reviews will take place at the weekly MDT meetings where the sector Consultant Psychiatrist and CMHT will be informed of the progress of service users resident in that sector. Feedback will also be given to the MDT about service users from that area who are assessed but not taken on. 17.2. Regular team meetings will be held by the CRHTT to review processes and reflect on any arising issues. 17.3. CRHTT members are encouraged to seek professional supervision from a professional of their choosing within the Directorate. 18. Discharge 18.1. The CRHTT will plan for discharge with the service user as soon as the immediate crisis has been contained. The need for ongoing care will be established and effective transfer to other agencies, if appropriate, arranged. 18.2. The CRHTT will prepare for discharge through a planned reduction of contact, as agreed with the service user and the care coordinator, if involved. Discharge must be agreed with a senior medic. On discharge the service user will receive a copy of their crisis plan and agreed discharge plan if applicable. 18.3. Discharge from the CRHTT will take place when agreement is reached between the Team, the service user and the CMHT that further Home Treatment is unnecessary. 19. Audit and Quality 19.1. The service will be evaluated through: Daily handover and case discussion Service user and carer satisfaction evaluation Regular internal documentation audit All Wales CRHTT network audits AQF statistics, produced monthly for the Welsh Government.

20. Unmet need/capacity 20.1. As the HTT must provide a crisis assessment service to those who are felt to be in need of an acute intervention, the Home Treatment function of the Team maybe restricted at time of great demand, or reduced Team resources. It is essential that during these circumstances that the service is provided safely. 20.2. During times of high capacity the team will priorities the workload taking into account the current caseload and AQF Targets, it is suggested that the priority of activity is as follows: Those currently on the caseload and facilitating their safe Home Treatment through to discharge. Crisis Assessments/ Gatekeeping (AQF Target) will be undertaken. Those identified from assessment as being suitable for Home Treatment but there is no capacity for the HTT to take them on should be admitted to Inpatient areas until they can be picked up safely by the HTT. Unmet Needs forms should be submitted if this occurs. Enlisting the support of the CMHT in undertaking these assessments should the demand be excessive may need to be considered. Follow-up Assessments (AOF Target) will be undertaken - again the team will not be able to facilitate the early discharge until the individual can be picked up safely. 20.3. Due to the varying level of intensity of Service Users needs there is not a definitive number that the HTT s can accommodate on their caseload. It is suggested that a total caseload number of 17 for the HTT should act as a prompt for the team to review its current activity. 20.4. Review of the team s activity should at minimum consider the number of essential visits required, visits that require more than one member of staff and contacts that can be delayed or provided in an alternative way. 20.5. Any decision to restrict the HTT s activity will be communicated to the CMHT s, Team Leaders and Consultant Psychiatrists for the relevant catchment and the Directorate Management Team by the Senior Nurse or their delegate. This will be reviewed on a daily basis. 20.6. The Team will register as an unmet need any failure to provide a Home Treatment package due to lack of capacity. The HTT will monitor and record unmet need as it is identified through the relevant CTP documents and submit them to the CTP Board.

21. Standards and Outcomes 21.1. The CRHTT will assess those referrals that are deemed appropriate within 4 hours of receipt. 21.2. The CRHTT will gate keep at minimum 95% of all admissions to Talygarn / Carn y Cefn units with the aim being 100%. 21.3. The CRHTT will provide follow up assessment for discharge to Home Treatment, to all service users (100%) admitted to Inpatient services outside CRHTT hours, within 24 hours of admission to the Inpatient unit. (AQF Target 13) 21.4. Service users appropriate for Home Treatment will receive a signed copy of their initial safety plan at completion of the initial assessment. 21.5. A written copy of the assessment outcome and Home Treatment plan will be dispatched to the referrer and the GP within 72 hours of assessment. 21.6. A written copy of the Home Treatment safety plan will be given to each service user. 21.7. A written copy of a discharge summary will be dispatched to the referrer and the GP within 3 days of discharge from the CRHTT. 21.8. On discharge from the CRHTT each service user will be given a written copy of their discharge and crisis plans. 22. Review of Operational Policy 22.1. This document is applicable from the 1 st, and will be subject to a formal review by the 1 st June 2016. 22.2. The procedures outlined within this document will be reviewed and adapted as necessary, in line with good practice, via Team meetings and supervision.