Rehabilitation and High Support Directorate

April 2006 Appendix 1 Reviewed January 2008 Reviewed December 2009

Clinical Pathway Team Assessment and Monitoring Protocol

1. Introduction

The Rehabilitation and High Support Directorate aims to develop a range of services that will reduce the overall dependence upon out-of-area placements for individuals with complex mental health needs.

The National Service Framework (NSF) for mental health emphasises the need for access to local services. Standard 5 states:

‘Each service user who is assessed as requiring a period of care away from home should have timely access to a hospital bed or an alternative placement which is in the least restrictive environment consistent with the need to protect them and the public and as close to home as possible’.

The Clinical Pathway Team aims to:

i) Facilitate the return of people in out-of-area placements ii) Reduce future dependency upon out-of-area placements iii) Bring financial benefits to partner agencies iv) Provide advice and support in identifying appropriate pathways for individuals with complex mental health needs

2. Role and Function of the Clinical Pathway (OAT) Team

The Clinical Pathway Team will undertake to ensure up-to-date and accurate information is made available to the Rehabilitation and High Support Directorate senior management team to enable the future planning of services to be based around identified continuing health and social care needs of individuals to ensure the best possible outcome for each individual.

The team will focus on service user who have complex mental health needs and frequently present behaviour that is deemed challenging to existing mental health services. It has been recognised that this group of service user will require different levels of physical or relational security in either the short, medium or long term period of time depending upon their individual clinical need.

1 April 2006 Appendix 1 Reviewed January 2008 Reviewed December 2009 The Team will operate from the Rehabilitation & High Support Directorate and provide specialist advice regarding alternative pathways for individuals where there is rehabilitation need identified. This may result in agreed admissions within existing provision or a suggestion of more appropriate services. The team will work in conjunction with care co-ordinators and Responsible clinicians; clinical teams and other agencies where necessary. The aim will be to ensure good communication is maintained and that the work undertaken by the team is viewed as an additional specialist resource to aid and support clinical care planning and effective risk management formulation and developing appropriate care pathways for service users.

The team aims to:

 Identify potential cohorts for reprovision  Maintain an accurate and up-to-date database of all the cohorts from each of the Boroughs  Carry out a range of holistic clinical assessments to identify need  Identify risk areas and issues related to individual clients  Participate within a multi-disciplinary process of future placement planning  Monitor and advise on current secure placements and encourage moves into less secure environments supported by intensive packages of care where necessary  Liaise with the range of service commissioners, providers and statutory and non-statutory agencies involved with service users  Ensure on-going communication with North West Specialist Commissioning Team, local PCT, Borough leads and clinical teams regarding secure placements.  Provide support and advise to commissioners, care coordinators/key workers in future planning and the development of complex packages of care  To attend CPA/ECC reviews where required  To use agreed standards of documentation, care planning, risk assessment and record keeping.  Maintain a reporting system that provides detailed information on current placements and care plans when requested.  To undertake reviews of service users awaiting admission, and to complete pre-admission work with service users identified for admission to the range of F&HS in-patient units.

3. Assessment Process

The Clinical Pathway Team will undertake a range of informal and formal assessments of clients in a number of different settings within the Trust footprint but also in OAT placement across the country:  Low secure units  Medium secure units  High secure hospital  Specialist Learning Disability Hospital  Nursing Homes

2 April 2006 Appendix 1 Reviewed January 2008 Reviewed December 2009  Psychiatric Intensive Care Units (PICU)  HM Prisons  Acute mental health services (clients awaiting transfer to a secure environment)  Residential homes

The types of assessments undertaken include:

i) Initial Assessments The initial assessment will be undertaken on all service users referred to or identified by the team. This assessment involves scrutinising the MDT clinical record; discussion with care team members and the client if deemed appropriate to do so. Information is recorded on a standardised assessment form and captures information related to specific areas:  Historical information  Current symptoms  Current problems  Current interventions  Risks associated with illness  Psychiatric medication  Physical health problems  Family relationships  How the illness affects the client  Reason for OAT placement  Summary of the assessment  Recommendations for future services.

ii) Specialist Assessment The specialist assessment involves a more in-depth assessment with a greater focus upon service user engagement and the assessment and management of risk. This assessment involves a more structured approach to ensure reliability and accuracy of the information and the final outcome of the assessment by utilising a range of specific assessment tools. The assessment process requires the practitioner to have good clinical management as well as skill, experience and careful judgement, applied to a sound base of information and knowledge. The assessment should include:  Historical factors related to the development and course of their illness  Rehabilitation history related to their offending behaviour  Current mental health/behaviour presentation  Circumstances of their current placement  Current plan of care  Past effective and ineffective interventions  Early warning and relapse indicators  Unmet needs  Level of support needs  Carer or support networks

3 April 2006 Appendix 1 Reviewed January 2008 Reviewed December 2009  Risk assessment, including identifying protective factors  Rehabilitation need  Recommendation for future services

4. Information and Case-Load Management

The management of the Team’s case-load is undertaken on a weekly basis. A centrally managed database holds the relevant information regarding all OATS from the surrounding boroughs across Pennine’s footprint. This information system is up-dated on a regular basis following each visit by a pathway nurse. The database includes:  Client name  Responsible PCT  DOB  DOA  Diagnosis  Current Placement  Type of service  Care Co-ordinator  Future need (type of service)  Date of next CPA  Cost of placement

It is critical that the information is regularly up-dated as the OATs list can be very dynamic. Those individuals in long term placements will be reviewed on an annual basis; medium term placements 3 – 6 monthly and short term as required. The monitoring timescales provide the team with guidance on frequency of reviews but can be flexibly operated to facilitate a more robust monitoring process where necessary. The stored information will be validated with PCT leads at borough monitoring meetings and the recommended outcomes of assessments will be discussed. The allocated nurse will ensure regular attendance at CPA reviews and other clinical review meetings if deemed necessary and ensure the relevant stakeholders receive a written report of any potential pathway recommendations.

The Pathway Team operates from a team approach basis with each practitioner taking a lead role in an allocated case but with involvement from other members when necessary. Case-loads will be reviewed during the OATs Meeting which is chaired by the Pathway Manager/Deputy. The meeting provides a forum for team discussion, sharing of information, an exchange of views and combines the experience and expertise of each team member. Decisions are recorded and future plans detailed in individual case notes.

Where a pathway is identified that indicates an internal placement would be appropriate, the RHSD Referral process will be implemented. In cases where an alternative pathway is through other services the process will be communicated to the care co-ordinator and assistance made available to facilitate the necessary PCT process.

4 April 2006 Appendix 1 Reviewed January 2008 Reviewed December 2009 5. Service Development

A major component of the Pathway Team’ role is to collate information related to OATs and to utilise that data to create opportunities to establish local developments through local Service Development Groups; commissioning meetings and joint planning initiatives. The fundamental aim being to ensure services uses have access to locally developed rehabilitation services.

Joyce Parkinson Divisional Clinical Pathway Manager