HOME TREATMENT SERVICE OPERATIONAL PROTOCOL

HOME TREATMENT SERVICE OPERATIONAL PROTOCOL Document Type Unique Identifier To be set by Web and Systems Development Team Document Purpose This protocol sets out how Home Treatment is provided by Worcestershire Health and Care NHS Trust Document Author Target Audience Worcestershire Health and Care Staff, patients, carers and all other stakeholders of the service. Responsible Group Date Ratified Expiry Date This validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email communications@hacw.nhs.uk Version History Home Treatment Operational Policy 1 of 13

Version Circulation Date Job Title of Person / Name of Group circulated to Brief Summary of Change Accessibility Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number (0800 084 2003). Interpreters and translators are available for over 150 languages. From this number staff can arrange: - Face to face interpreting - Instant telephone interpreting - Document translation - British Sign Language interpreting Training and Development Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. Home Treatment Operational Policy 2 of 13

Contents page 1. Introduction. 2. Definitions... 3. Scope.. 4. Training / Competencies.. 5. Team roles and responsibilities.. 6. Hours of Operation 7. Capacity.. 8. Interfaces and Inter-team working.. 9. Access to Home Treatment..... 10. Response times. 11. Content of a Home Treatment Episode. 12. During an episode of Home Treatment.. 13. Exit from Home Treatment... 14. Carers support and involvement... 15. Patient and carer feedback.. 16. Team Safety... 17. Accessing and recording clinical information.... Appendices 1. Home Treatment bases and catchment areas. 2 2. Training / Competencies... 4 3. Team roles and responsibilities.. 5 4. During an episode of Home Treatment.. 11 5. Access to Home Treatment. 12 6. Content of a Home Treatment Episode. 15 7. Exit from Home Treatment... 18 8. Carers support... 19 9. Operational Arrangements for staff safety. 20 10. Documentation... 21 Home Treatment Operational Policy 3 of 13

Home Treatment Operational Policy 4 of 13

1 Introduction 1.1 The provision of Home Treatment reduces the frequency and length of hospital admissions for people experiencing an acute episode of mental illness. 1.2 Home Treatment teams have a recovery focus in their work with patients and carers, seeing each patient as an integral part of a family and community. 1.3 Staff are optimistic about patient s prospects of recovery from severe mental illness and help patients to develop aspirations which drive their recovery. Patients are viewed as part of a network. Support to and collaboration with carers is core role of the Home treatment service. 1.3.1 Care is provided in the least restrictive environment, with the minimum disruption to their lives to meet the person s clinical and safety needs, providing credible alternatives to hospital admission. 1.3.2 The person remains in contact with their own resources and support networks, allowing treatment to utilise the individual s strengths. 1.3.3 Carers can be actively involved in all aspects of care with the patient s consent. 1.3.4 The person retains responsibility for him/herself, fostering independence and greater self-reliance. 1.4 Home Treatment therefore plays a crucial role in supporting the organisation s phased reduction in acute psychiatric inpatient beds. 1.5 This document provides the first guidelines for the reconfigured Home Treatment service the headline changes to the service being: 1.5.1 Provision of a Home Treatment team for each of the four adult community mental health team localities 1.5.2 Co-location of Home Treatment with the inpatient facility within the locality the team covers 1.5.3 The functions of Crisis Resolution / Home Treatment (CRHT) being separated into: - Home Treatment provided by 4 Home Treatment (HT) teams - Crisis and Assessment provided by a county wide Assessment (AT) team 2 Definitions 2.1 Gate keeping inpatient psychiatric admissions 2.1.1 All people deemed in need of psychiatric admission to a functional acute ward (ie excluding organic mental health wards) are assessed for the opportunity to be treated in their own home, rather than being admitted to hospital. 2.1.2 This assessment will be by the Assessment team, an Home Treatment Team or a Mental Health Liaison Team. 2.1.3 Gate keeping ensures all patients have the opportunity to be assessed for treatment at home. 2.1.4 The Assessment team and Mental Health Liaison teams work closely with the Home Treatment teams and can accept patients onto the Home Treatment case load, without the need for reassessment by Home Treatment. 2.2 Alternative to hospital service 2.2.1 Providing intensive home based support and treatment. 2.2.2 Facilitating discharge from in-patient care at the earliest opportunity for each patient. Home Treatment Operational Policy 5 of 13

2.2.3 Patients can remain at home or return home after a shorter admission and receive the treatment they need to start recovery from an acute episode of illness. 2.3 Threshold of admission 2.3.1 People who would need admission to a psychiatric inpatient bed if Home Treatment was not available to them. 2.3.2 People who have been in hospital but could not be safely discharged without Home Treatment input. 2.4 Community based mental health teams 2.4.1 All teams working in the community with people who have mental health problems, for example Recovery teams, Assertive Outreach, CMHTs, Early Intervention (Psychosis) and CAMHS (Child and Adolescent Mental Health Service). 3 Scope 3.1 The patient group remit of Home Treatment This guidance is to assist the referrer. All referrals will be discussed on individual presentation: 3.1.1 People aged 16 years and older with functional mental illness, including - Young people aged 16 18 regardless of whether they are in education, under adult services or CAMHS. - Older people aged over 65 regardless of whether they are under adult or older adult services. 3.1.2 AND are on the threshold of psychiatric hospital admission due to an acute episode of mental illness. 3.1.3 AND who fall within one or more of the following presentations: - Severe and persistent mental disorders associated with significant disability. Such as, schizophrenia, bipolar (manic depressive) disorder and severe depression. - People whose presentation requires an inpatient assessment and diagnosis to provide clarity of their mental health needs. - Longer term disorders of lesser severity, but characterised by poor treatment adherence requiring proactive follow up. - Mental health problems where there is a significant risk of self-harm or harm to others (e.g. acute depression) or where the level of support required is beyond what the community based mental health teams set up to provide. - People who have a dual diagnosis (eg Mental illness with Learning Disability, alcohol or substance misuse) will not be excluded. - Clozapine initiation in the community as an alternative to initiation as an inpatient. - Patients with severe disorders of personality that require short term input to assist them to manage aspects of their condition. Home Treatment Operational Policy 6 of 13

3.1.4 Individuals with an organic illness can sometimes be suitable for Home Treatment if the acute medical issues have resolved e.g patients with head injury/epilepsy etc who have mental health problems due to a chronic organic cause. 3.1.5 In order to provide a service to those who are at greatest risk of requiring a psychiatric hospital admission, HT Teams are less likely to offer a service for the following conditions: - Mild or Moderate anxiety disorders - Primary diagnosis of alcohol/substance misuse - Primary diagnosis of a learning disability - Recent history of self harm, but not suffering from a mental disorder - Organic mental illness - A crisis related solely to relationship issues/or other social issues 3.1.6 Home Treatment teams are not able cover the leave of a patient s community mental health team worker. 3.1.7 Patients with mental illness secondary to physical, organic or neurological conditions who do not have acute medical issues may be suitable for HT. 3.1.8 HT may not accept referrals where there is no indication that HT input will have therapeutic value. 3.1.9 Where young people aged 16 18 years are under the care of Home Treatment this is in collaboration with CAMHS (Child and Adult Mental Health Service) and in accordance with the policy for the transition of clients from CAHMS to adult mental health services (ref: CP0009). 3.2 Home Treatment bases and catchment areas (Appendix 1) 3.2.1 For consistency with other services, the catchment area for each HT team is defined by the GP surgeries each patient registers with. 3.2.2 The four HT teams each cover a locality of Worcestershire and are co-located with the adult mental health inpatient facility for the locality. 3.3 The staff group 3.3.1 Average establishment of each Home Treatment team, although there are variations according to local differences - Clinical Team Leader band 7 (1) - Consultant Psychiatrist (0.5) - Staff Grade Doctor (0.25) - Community Psychiatric Nurse / Occupational Therapist Band 6 RMN / OT (4) - Approved Mental Health Professional / Social Worker AMHP (1) - Community Psychiatric Nurse / Occupational Therapist Band 5 RMN / OT (1.5) - STR (Support Time and Recovery) Workers - Band 3 (2) - Team Administrator (1) 3.3.2 A service lead (band 8a) directs the 4 clinical team leaders. 3.4 Location of service delivery 3.4.1 Patients are seen in a wide range of available environments / locations, according to each patient s identified recovery needs and safety considerations. This includes: - At home Home Treatment Operational Policy 7 of 13

- At the home of patients family and friends - Inpatient ward - In a range of community venues (according to the needs of the patient) 4 Training / Competencies 4.1 Education, training and development play a central role in supporting good practice and delivering safe and effective care whilst considering the developmental needs of team members. 4.1.1 All team members have annual appraisals / personal development reviews, to ensure that their personal training and development requirements are identified; these take into account profession specific needs. 4.1.2 Training and development activities are made available to staff to ensure they can meet the developing needs of the Home Treatment service and the wider organisation (appendix 2). 4.1.3 Staff complete statutory and mandatory training appropriate to their individual professional status and role as required by the organisation. 4.1.4 Team members are encouraged and supported to foster links and pursue development activities within their own professional group, for example via professional updates and forums. 4.1.5 Staff will be assisted where necessary to organise support and supervision within their own professional group. This may be of particular significance where there is only one member of a discipline within a team. 4.2 All new staff, including locum and bank shift workers complete an induction programme. The breadth/content of the induction programme is tailored to individual needs. 5 Team roles and responsibilities (Appendix 3) 5.1 Each Clinician within the Home Treatment Team holds specialist knowledge and expertise in supporting individuals experiencing acute mental illness. 5.1.1 All disciplines contribute both professional specific and generic skills to their team. Each team member is professionally responsible for the patients under their care and for recognising the limits of their own training or role. This includes the responsibility to seek appropriate supervision within the team and their professional structure. 5.2 The Named worker system is used to support home treatment in delivering consistent care and making every contact count (Appendix 3) 5.2.1 When under the care of HT each patient is allocated a 1 st and 2 nd named worker. 5.2.2 The named workers have responsibility for the majority of a patient s contact with HT and for jointly planning the patient s care with the patient, carer and other involved services. 6 Hours of Operation 6.1 7 days / week (including bank holidays) 8am to 10pm 6.1.1 Outside these hours crisis support for people who are under the care of home treatment and their carers is provided by our sister service, the Assessment team (Appendix 4). 7 Capacity Home Treatment Operational Policy 8 of 13

It is essential that the service has capacity to retain flexibility around visiting. Duration, frequency and intensity of visiting will be a key requirement to successfully deliver an alternative to hospital admission West Midlands Regional Development Centre (2009) Service Specification CRHT final. 7.1 To support provision of a flexible and safe Home treatment service the guide caseload capacity for a team of the equivalent of 10 full time staff is 21 patients. 7.1.1 This figure is based on each full time staff member completing 15 contacts per week and patients requiring an average of 7 contacts per week (e.g. daily contact). 7.1.2 It is likely that each inpatient open to HT requires less of the teams time, with the majority of care being provided by the inpatient unit. Each inpatient may therefore be considered as 0.5 on the caseload, rather than 1. 7.1.3 This figure is also in line with national guidance on capacity of Crisis Resolution / Home Treatment teams. 1.2 Capacity is highly variable, due to: - Changing needs of each patient (acuity and risks) requiring increased frequency and / or length of contact. - Travel time to for every patient contact 1.3 Where a team has fewer than 10 staff there is less flexibility which has the effect of compromising team capacity more than pro-rata. 1.4 Where a team has no capacity to take on a patient who needs the service the following actions are taken: - Rearrange the current workload - Make use of colleagues in other home HT teams (i.e. cross cover). 7.1.4 Consistency is an essential quality of HT provision, this is threatened when work with patients is cancelled, delayed or altered due to lack of capacity Such incidents are reported using Sentinel (the Trusts electronic incident reporting system). 8 Interfaces and Inter-team working 8.1 The short term nature of Home Treatment work means that every patient requires Home Treatment named workers to liaise with colleagues in other services, teams and agencies. 8.1.1 This requires careful attention to interfaces between services and close cooperation between mental health teams. Home Treatment teams commit to addressing professional concerns or differences promptly without impacting on patient care. 8.1.2 Day to day issues are discussed and resolved by the staff concerned with the support of their line management. 8.1.3 Regular meetings between teams are held to specifically address interface issues. These are held regularly with the following services; - Inpatient units - Community Mental Health teams o Older adult mental health teams o CAMHS Home Treatment Operational Policy 9 of 13

o Adult mental health teams - Assessment team - Mental Health liaison service And are arranged with other services as required. Common interfaces are described in sections 9, 12 and 13 (with greater detail covered in appendices 5, 4 and 7). 9 Access to Home Treatment (Appendix 5) 9.1 Access is carefully defined to reduce the risk of consistency of care and treatment provided being disrupted by crisis assessments 9.2 Home Treatment accepts patients from: - Community based mental health teams - Inpatient mental health teams - The Assessment Team and the Mental Health liaison service 9.3 Services other than the mental health teams (e.g. Primary care, acute hospitals, drug and alcohol services) cannot refer directly to Home Treatment. (Ref. Adult Acute Pathway Policy) 9.4 Self referrals to HT are not accepted; however wherever possible HT staff will advise people how they can access services. 9.5 Referrals can only be accepted following a discussion between the referrer and Home Treatment team. Written records must also be provided (i.e. mental health assessment and care plan, risk assessment). 9.6 It is the responsibility of the referrer to ensure that patients and carers are aware that a referral has been made to HT. Home Treatment Operational Policy 10 of 13

10 Response times 10.1 The time between referral and initial contact with the patient is less than 48 hours. 10.1.1 The timely response for each referral will be discussed at the point of referral with the referrer. It is most likely to be determined by risk factors. 10.1.2 Any cases not seen within this time frame should have clearly documented clinical rationale. 10.2 Telephone calls 10.2.1 HT staff are mostly out of the office (carrying out their clinical work with patients). Phone calls will be answered by admin staff during their working hours and by using voice mail system outside these hours. 10.2.2 In most instances staff will not interrupt contact with a patient to respond to messages. 10.2.3 Clinical Staff endeavour to respond to all messages within 1 ½ hours 10.2.4 Patients and carers are made aware of this when they first meet Home Treatment staff. It is reiterated in the Home Treatment information leaflet provided on admission to the service. 11 Content of a Home Treatment episode the treatment (Appendix 6) 11.1 Central to the successful provision of HT is staff s acceptance and understanding that mental health problems occur within the greater context of peoples lives and should not be viewed in isolation from this. 11.2 HT staff are clear about the purpose and course of an episode of Home Treatment from day one. Both in discussion with patients, carers and colleagues and in their documentation. This is considered essential to delivering a recovery focused service. 12 During an episode of Home Treatment (Appendix 4) 12.1 HT teams commonly liaise and work jointly with: - Community mental health teams - Inpatient teams - GPs - Assessment team Home Treatment Operational Policy 11 of 13

12.2 Interfaces with other services and agencies are driven by the needs of each patient and his or her circumstances 13 Exit from Home Treatment (Appendix 7) 13.1 Home treatment may discharge patients to the care of their originating mental health team or to their GP. 13.2 Discharge planning commences on admission to Home Treatment 13.2.1 It is usual for Home Treatment input to be gradually reduced (according to patient need) in a stepped approach towards discharge 13.2.2 Home Treatment named workers complete discharge summaries within four days of discharge; this includes details of medication to be prescribed. 14 Carers support and involvement (Appendix 8) Carers are often integral to a service user s support system and their input and support can substantially improve that person s chances of recovery. The Triangle of Care (2010). The Princess Royal Trust for Carers 14.1 Although many carers prefer the patient to avoid hospital admission, being in close proximity 24/7 to a person who is unwell, can place a carers under considerable strain. Home Treatment teams are mindful of this and work to support and involve carers. Home Treatment Operational Policy 12 of 13

15 Patient and carer feedback 15.1 Patients and carers are provided with questionnaires to feed back on their experience of HT. This gives an option for anonymous responses. 15.2 HT teams ensure patients know how to contact PALS (Patient Advice and Liaison service) should they chose to do so (policy ref: TC0078). 16 Team Safety 16.1 The safety of HT workers is paramount to the ability to provide an effective service. 16.2 HT workers frequently work alone in the community and face a variety of challenging situations. 16.3 The acuity of HT patients conditions and degree of distress they are experiencing can be a particular issue for staff safety. 16.4 Comprehensive and contemporaneous risk assessment and risk management plans are key in providing Home Treatment. 16.5 Team members comply with the Lone Worker Policy (ref TC0102) and Incident Reporting using the Sentinel System (policy ref: TC0048). 16.6 Home Treatment staff are supported by their management to apply a policy for zero tolerance of discrimination, physical or verbal abuse (Policy for Managing Actual or Potential Aggression ref: CP0033). 16.7 For operational arrangements for staff safety see appendix 9 17 Accessing and recording clinical information (appendix 10) 17.1 The HT service currently documents contacts with patients on an electronic Patient Administration System 17.1.1 Information is shared with other services and agencies involved in the person s care on a need to know basis, by E-fax. 17.2 HT staff can access all local health and social care electronic record systems, to ensure awareness of any relevant information. 17.3 Clinical records are kept according to the requirements of staff s professional bodies and Trust policy. 17.4 All patients will have a Risk Assessment, which will be appropriately updated to reflect significant changes in risk. 17.4.1 Appropriate information sharing regarding risk assessment with others involved in the patients care is essential. Home Treatment Operational Policy 13 of 13