The Key Values and Principles of the Service Are

1. PART ONE OF THIS POLICY WILL BE RELEVANT TO BOTH PARTS OF THE URGENT CARE SERVICE WITHIN THE MENTAL HEALTH PATHWAY, ACCESS AND LIAISON INTEGRATED SERVICE AND HOME TREATMENT SERVICE

1.1 Philosophy

The key values and principles of the service are:

 To work in partnership to assess and support people experiencing mental health difficulties and their carers.

 To provide a service to all adults over the age of 18 in Cumbria where their mental health is the primary concern regardless of any agencies or services that may already offer support and care.

 To adhere to the principles of compassion, honesty, openness and integrity in their work

 To adhere to the Trust values of, kindness, fairness, ambition and spirit.

 To adhere to the principles of CQC KLOE, (are we safe, are we effective, are we caring, are we responsive and are we well led?)

 To provide individualised care that recognises each person’s unique pathway to recovery.

 To provide safe care in the least restrictive environment

 To provide partnership working, and effective communication when working with other agencies to support the service user’s journey through the service using evidence based practice incorporating NICE guidelines, NMC/GMC/Heath and Care Professional Council principles

 To adhere to all CPFT policies and procedures.

1 1.2 Role of the Service

The role of the service is provided in three pathways:

 The Access Service which provides assessments into the urgent care pathway.

 The Psychiatric Liaison Services provide assessments in the Acute Hospitals and links with the Access and home treatment teams

 The Home Treatment team provides continuous assessment and treatment for up to a period of six weeks (or as directed by clinical presentation) within the service users home environment

1.3 Definition of service

The Access and Liaison Integrated Service (ALIS) is a dedicated service within the Urgent Care pathway for Mental Health Care Group delivered by Cumbria Partnership NHS Foundation Trust.

The Psychiatric Liaison Service provides assessment, support and education into the Acute Hospitals Trusts.

The service provides intensive assessment for up to 72 hours. It provides individuals in mental health difficulties with prompt and effective mental health assessment, including Mental Health Act Assessment (where necessary), advice, support and short term interventions, signposting, onward referral, and support to carers.

HOME TREATMENT

The Home Treatment Service (HTS) is a dedicated service within Urgent Care provided by CPFT. The service is designed to:

2  Provide intensive home treatment support for people with mental health needs to prevent further deterioration in their mental health

 Avoid inpatient admissions

 To support early discharges from hospital where appropriate.

1.3.1 General Shift Patterns and staffing

Within the service, there is qualified cover over a 24 hour period 7 days a week. The team lead is responsible for the planning and implementing of the duty rota and will make necessary changes in line with service need. Any changes out with this to meet the needs of the service can be agreed within local teams; these changes will be authorised by the operational team lead/manager or clinical lead. Out of hours cover for any changes to staffing e.g. short term sickness should be authorised by the team lead with network manager(s) support when required. On occasions other ALIS/HT teams may cover the telephone lines, due to clinical work or staffing resources, details of caseload will be shared across the county.

Rotas will be prepared at least 6 weeks ahead and will be approved in advance by the team leader. Staffing will reflect local needs and demands. There will be occasions when there are significantly higher than usual demands on either Home Treatment or ALIS service in these instances the team leader will review the staffing levels in both teams and realign staff between services dependant on clinical need and demand. The ALIS and HTS operate as a county wide structure which will mean there will be occasions where staff are required to work outside their usual locality. Staff will be deployed to the nearest locality where there is a clear service need identified. The network manager(s) will authorise staffing deployment across the county when required and out of hours this will be the bronze on call manager.

1.3.2 Carers

All teams have a duty to identify carers and to offer carers assessments where applicable. The service acknowledges the roles fulfilled by carers and strives to work collaboratively with individuals and their carers. Carers will be offered time to discuss their concerns and impact of their caring role on their physical and mental health wellbeing. However, it must be

3 noted that the rules of confidentiality apply to staff and where an individual service user refuses consent for their condition and care to be shared with carers; this must be respected in accordance with law. On occasion, specific types of risk override this; however, all staff will be familiar with these conditions. Where a service user refuses consent for their personal information to be shared and this has to be respected by staff, staff will attempt to discuss general information with carers (not personal) in relation to whatever aspects they can.

All children within the family will be recorded in the assessment form. For children under 5 the relevant health visiting team and any other agencies will be liaised with. All practitioners are aware of the impact of mental health within a family unit and will assess a parent’s capacity to care for the children they have parental responsibility for wherever they live.

All practitioners can also refer onto 3rd sector providers for the carer and provide the carer with the numbers and contact details of carer organisations. Carers are given a 24 hour contact number for the service

1.3.3 Memory and Later Life Mental Health Needs

Wherever possible, ALIS/HT practitioners will liaise closely with Memory / OA services when dealing with an assessment of an individual with dementia/ older adult needs. In addition where Memory Services have an existing client who requires input, Home Treatment practitioners will work jointly with Memory Service staff to provide robust home treatment.

1.3.4 Interface with CAMHS and Children’s Services

ALIS/HT will offer mental health information, advice and support for children out of hours. All children referred out of hours will be discussed with the CAMHS on-call and if necessary the on-call consultant psychiatrist. It may be necessary for ALIS/HT practitioners to assess children out of hours.

 Children under the age of 16 years presenting in the Acute Hospitals will be referred to paediatrics and be referred to CAMHS for urgent review the next working day

 Children 16yrs – 18yrs will be supported by ALIS/Home Treatment team until the next working day when an urgent referral to CAMHS assessment/review will be completed

4 1.3.5 Interface with specialist Drug and Alcohol Services

There is a close working relationship with agreed pathways for referral into the specialist drug and alcohol services from the Acute Hospital trust.

Any service user with identified substance misuse problems should be offered interventions including referral to specialist substance misuse services. All staff work within the Dual Diagnosis Protocol (POL-001-021 CPFT intranet) which supports co-working when there is an identified mental health and substance misuse problem identified

1.3.6 Interface with Learning Disabilities

Any adult presenting with a primary acute mental health episode will be able to access ALIS/HT including adults with Learning Disabilities.

ALIS/HT staff should liaise as soon as possible with the relevant Community Learning Disability Team and the individual will be supported through joint working between the two teams to ensure where ever possible that care is delivered within the community rather than facilitating a hospital admission. The appropriate risk assessment tool will be used (GRIST).

If an individual presents out of hours and does require a hospital admission, the ALIS staff will identify an appropriate inpatient bed. This may involve admitting someone with a Learning Disability (LD) to an acute mental health inpatient ward if appropriate or an admission to the LD inpatient ward.

If there are no available beds then the ALIS team will source an appropriate out of county bed with the authorisation from the silver on call manager.

Discharge from an inpatient facility will follow a multi professional review meeting and where necessary, joint follow up by the LD team with the support of the appropriate mental health team. Within the LD service, individuals with co-morbid diagnosis of both LD and MH should be subject to CPA and will be managed in accordance with CPA procedures and policies. Where the needs of the individual relate primarily to LD, then the care coordinator will be a member of the LD service.

1.3.7 Interface with the police

5 Referrals from the police should also go through single point of access telephone number. There is no defined response time but it is expected that wherever possible it should be within 4 hours. Service users referred by the police will have a full mental health and social needs assessment including risk formulation and management plans.

The MDO protocol guides practitioners regarding the assessment and management of those in custody.

1.4 Single Point of Access (SPA)

The SPA line (0300 123 9015) is a county wide service 24 hours per day SPA call handling is a single point for all referrals into the service.

Call monitoring is in place for the purposes of training and continuous improvement. These arrangements will enable a consistent approach in the gathering and the quality of information. The role of the single point of access worker is to gather the information required which includes:

 Demographics of the service user,

 A summary of current presentation,

 Mental health needs,

 Relevant history particularly relating to risk

 Expectations of referrer.

The SPA worker will contact the local GP surgery or use DCR (if not the referrer) to gain relevant information on current medication, allergies and physical health. The SPA line worker will complete the Threshold Assessment Grid (TAG) to help to inform the level of risk in relation to safety and to agree with the referrer the expected timeliness of intervention which will be within 2 and 24 hours. ALIS will accept all referrals without exclusion. Wherever possible, ALIS will respond to the referral within the timescale requested by the referrer or as directed by the risk identified.

Role of ALIS/HT practitioner

The shift lead will make contact with the service user within 4 hours, unless requested sooner by the referrer or if significant risks are identified. This is to gain further information to establish rapport, provide basic information regarding expectations and confirm appointment time, named practitioner and place. At the point of referral and initial assessment consent is assumed and practitioners will adopt assertive engagement skills. The assessment of an individual’s capacity will be an important consideration at this point. If the service user declines assessment and a Mental Health Act assessment is not required the practitioner in ALIS must contact the referrer to have a discussion about the way forward and agree further management plan.

Information is gathered via Integrated Patient Management (IPM), Integrated Electronic Records (IER) and IAPTUS with RIO scheduled to be online in late 2016.

Service users (or their carers) who have been involved with Cumbria Partnership NHS Foundation Trust (CPFT) in the past three years will be able to self-refer. The referral process should be an integrated part of the service user’s crisis and contingency plan or discharge plan, with clear relapse signatures and coping strategies identified for the individual to follow and initiate when appropriate. Crisis and contingency plans must be detailed specific and should advise both the individual and ALIS how to recognise relapse, what actions are advisable in the event of relapse, who the individual can call upon to assist and support them at the time of relapse, the individual’s own views (recorded when well), arrangements for child care, pet care, who to inform, any advanced directives in place etc.

If a service user or carer contacts services and is already involved with CPFT then the practitioner will manage and plan the short term intervention in relation to the service users need. The care coordinator will be contacted on the next working day to handover the care over with relevant information, unless a Home Treatment role is identified.

1.5.1 Role of the Medical team within the ALIS and Home Treatment Service

Any patient who requires assessment, liaison or home treatment can be offered a medical assessment by a consultant psychiatrist or other senior doctor within the team. A number of interventions will reflect the needs identified in the assessment process and may include:

7  Specialist psychiatric assessment

 Pharmacological treatment initiation and review

 Diagnosis: effective management and treatment depends on accurate assessment of biological, psychological and social factors. Physical health assessment to ensure physical health is considered alongside psychological and social issues.

 Clinical advice to junior doctors, team members and regular or ad hoc supervision on clinical matters

 Attendance to clinical review meetings

 Doctors will be requested by team members to deal with complex cases and those deemed at particular risk and participation in ongoing review of formulation and management plans

 Medico-legal problems: The consultant psychiatrist will offer a medical expert point of view in discussions of this nature.

 Involvement in the training of other staff

 Liaison with colleagues and other services including GPs, general hospital consultants and other professionals

 Mental health assessments under the Mental Health Act for those patients under the care of the team

 Assessments of capacity

 Consultant will also provide formal responsible clinician role for the patients assessed and taken on by the team

1.5.2 Medicines Management

All practitioners will monitor service users taking their own medicines in their own home. This is defined as witnessing self- administration if the patient is seen to take their medicines by staff. The arrangements for monitoring a service user’s medication should be clearly recorded in the care-plan, including which medicines, how often and any other monitoring needed e.g. BP, temperature etc. On each occasion the team member attending the service user should record in the

8 medication administration chart that the service user has been prompted to take their medication, witnessed taking the medication, or the medication has been delivered to the service user.

There are times when medication will need to be removed from service users with their permission and this must be stored and recorded in line with Trust policy. There are times when medication will be prescribed for service users and also stock drugs. The medicines policy is available on the intranet and gives all up to date relevant information regarding medication. See POL001/013/004

1.6 Physical Health

 Physical health screening will be offered to all following the Trust Physical Health Assessment Pathway.

 Physical health screening will start at first contact with the referrer where any acute physical health problems are identified and a plan will be agreed to address this. The first contact will also include clarification of any medication, whether prescribed, over the counter or herbal, the service user is currently prescribed.

 The physical health screening and care plan will be continued in HTS or the GP will be informed of any concerns if discharged from ALIS.

 Heath promotion will be carried out where appropriate (given the individual’s mental health distress) in relation to smoking, alcohol and illicit substance use. Brief intervention should be offered and the response recorded in the clinical record. Referral to appropriate prevention services should be completed if the service user is accepting.

 Where medication is prescribed appropriate interventions and policies will be followed and in line with the shared care agreement

1.7 Outcome Measures - ALIS/HT key performance indicators

The key performance indicators will be agreed on a yearly basis and will reflect both KLOE and monitor targets including other performance management targets such as access to service and access to admission.

9  Alternatives to hospital admission, either informal or formal

 Reduced duration of inpatient stays

 Reductions in re-admission rates

 Reduction in admissions to residential care

 Reduction in referrals for care coordination by CMHT

 Cost benefits to the Council and the Partnership Trust

 Increased levels of carer support

 Reduced Out of County placements

1.8 Admission to Hospital

All practitioners requiring admission to beds for a service user will provide the following information via the admission referral form and take necessary actions:

 Legal status of the service user

 Risk management Plan with update to GRIST

 HoNos

 Identified need Indicators of relapse

 Perceived benefits of admission to the service user

 Agreed aims and outcome indicators with timescales

10  Anticipated interventions agreed during admission to allow discharge

 Anticipated treatment plan

 Anticipated length of stay

 Any safeguarding planning and referral

 Ensure child care provision is considered and where necessary, arranged

 Ensure pet care provision is arranged, encouraging the service user to do this wherever possible

 Ensure the service users home is secure

1.9 Failure to Engage/safe exit (see Appendix 1)

On occasions, service users disengage from service provision. This is their choice, however, if the disengagement relates to a situation where the service user has simply withdrawn from contact with the service, there will be a full MDT discussion the next working day where the risks will be assessed and plan of action agreed informed and GRiST updated. If the person is deemed risk of harm then the expectation is that all attempts at contact will be continued and this will include a cold call and if required police assistance. If the service user has a Care Coordinator, they may be asked to attend or inform the decision process.

If a relative/carer of such an individual has been involved in the care planning or delivery, or in contact with services and the service user has not barred an information exchange, ALIS/HTS will try and establish if they have any concerns. If there are risks and there is concern about safety, all efforts should be made to locate the person and discuss their wishes with them. Where contact has not been made and there are risks, the ALIS/HTS must contact the police and report the individual as a missing person in accordance with Trust policy. If this occurs out of usual office hours, the Trust on call manager must be notified.

11 Failure to engage indicators ie missed home visits/ withdrawal from service must be embedded into each care plan with agreed interventions based on clinical risk to be actioned ie contact family members/GP to ensure assurance of safety and well-being.

1.10 Safeguarding young people and Children

In some circumstances it may be necessary for practitioners out of hours to respond to referrals and prioritise the safety of children.

Children within families will be part of the comprehensive assessment process. Children under 5 within the family will be noted and correspondence sent to relevant health visitors following a phone call.

All staff have a duty of care to be aware of the definition of abuse, what they should do and who they should contact if they have any concerns at all about the welfare or treatment of adults who may be at risk. Detailed information is set out in the Cumbria Safeguarding Adults Partnership Multi-agency Procedures and Guidelines (POL/001/006).

In addition, all staff have a duty of care to be aware of their role and the systems and supporting in safeguarding and welfare of children and families in Cumbria and in working with other agencies of the Cumbria Local Safeguarding Children Board (LSCB). Detailed information is included in Trust POL/001/006

All staff must adhere to the mandatory requirements in relation to training in this regard.

1.11 Lone Working

All staff are expected to follow the Trust lone worker policy/guidelines in place. Everyone can access an up to date copy of the most recent policy/guidance on the Trust intranet.

12 1.12 Record Keeping

Following assessment it is expected that a GRiST including risk formulation and management plan is completed as a priority.

It is vital that contemporaneous notes are kept in the service user’s healthcare record. The team will follow Trust policies and procedures as well as their own professional codes.

1.13 Information sharing/confidentiality

Information relating to service users will be shared with relevant parties with the consent of the individual.

The teams will utilise all opportunities to work with both the service user and carers during the teams involvement in their care, we will offer information, advice and support to carers whilst respecting the service users wishes with regard to confidentially. We will ensure that any information provided to carers is correct and that the service user has consented for that information to be shared. This will be agreed through the use of an information sharing and consent form. Decisions to breach confidentiality are not taken lightly and are always discussed within the team (or in emergencies with a senior colleague) and documented within the individual’s clinical records. (POL/002/038)

1.14 Compliments and Complaints

The Trust takes all compliments and complaints seriously. The Trust aims to ensure:

 Ease of access for service users complainants

 A simplified procedure with common features for compliments and complaints about any of the services provided to service users

 Using complaints to improve the quality of services

13  Fairness for staff and complainants

 A more rapid, open process

 An honest and thorough approach with the main aim of satisfying the concerns of the complainant.

Staff should familiarise themselves with of the contents of the following:

POL/002/006/002 Untoward Incidents/Formal Complaints/Claims Investigation https://www.cumbriapartnership.nhs.uk/assets/uploads/policy- documents/Untoward_Incidents_Formal_Complaints_Claims_Investigation_Policy_POL-002-006-002.pdf

POL/002/002Complaints Policy Resource Pack https://www.cumbriapartnership.nhs.uk/assets/uploads/policy-documents/Dealing_with_Complaints_and_Comments_POL- 002-002.pdf

1.15 Supervision

Staff must comply with the CPFT supervision policies. Supervision protocols for both managerial and professional/clinical supervision have been developed. All staff within the service must comply with the protocols which can be found in:

https://www.cumbriapartnership.nhs.uk/assets/uploads/policy- documents/Clinical_Supervision_and_Peer_Review_Policy_POL-001-052.pdf

1.1.6 Appraisals

All staff will be required to have a yearly appraisal as per trust policy. The aim of this is to review individuals and teams roles, responsibilities, competencies and development.

14 1.17 Staff Training & Professional Development

There are training plans in place to support specific practitioners in the completion of non-medical prescribing and Approved Mental Health professional training to provide a high quality skilled and qualified integrated workforce enhancing the service user experience.

All staff will complete the mandatory training requirements as directed by CPFT

All staff should be committed to continuous professional development and should ensure they maintain any relevant professional registration. All registered nurses are now required to revalidate and as such must maintain personal records to meet revalidation standards

2. ACCESS AND LIAISON INTEGRATED SERVICE

2.1 Assessment

PSYCHIATRIC LIAISON

Within the hours of 08:00hrs to 20:00hrs there will be dedicated Psychiatric Liaison Service into the Acute Hospitals across the county. This service is integral to the emergency floor functioning within the Acute Hospital Trusts. After hours, 20:00hrs to 08:00hrs, this will be covered by ALIS. There is a requirement that if Acute hospitals provide suitable accommodation for the liaison team then they will base themselves there.

Assessments into Acute Hospital Trusts response times:

 2 hours (for A&E and MAU) within 09.00hrs -17.00hrs (4 hours out with core hours)

15  24 hours for all other wards The purpose of Liaison pathway is to work towards:

 Improving response to Emergency Department waiting times (within 2 hours)

 Reducing the number of patients whose discharge from hospital is delayed

 Effective management of self-harm and suicide risk

 Improved outcomes for service users with long term conditions and mental health co-morbidity

 Improved management of service users who frequently attend the Emergency Department.

Patients will be offered a full mental health and social needs assessment and risk assessment, formulation and management plan using evidence based tools tailored to the streams above (e.g. PHQ9, MMSE).

Liaison does not require patients to be medically fit for discharge before seeing them. Patients need to be psychologically able follow and undertake an assessment.

https://www.cumbriapartnership.nhs.uk/assets/uploads/policy-documents/Joint_Care_Policy_for_Patients_with_Physical %2C_Mental_or_Learning_Disability_Needs_POL-001-032_%281%29.pdf

Liaison practitioners will provide training and education to the Acute Hospital staff in relation to the management of self- harm, and suicide

South Lakes patients who are admitted to the Royal Lancaster Infirmary will be seen by the Lancashire Care Trust Liaison team and then referred to South Lakes team who will record information from the assessment into the Trust’s electronic records.

In some cases patients seen in the Acute Hospital will already be engaged with community mental health services and liaison staff will ensure timely and seamless transitions by liaising with community staff. For patients with ongoing needs who remain in the Acute Hospital, the Psychiatric Liaison staff will provide support as required in a “home treatment” role.

16 The Psychiatric Liaison Service will also provide support to service users who have been transferred from one of the mental health units due to their physical health care needs.

Service users who are assessed following first presentation or requiring medical intervention in the Acute Trust will be offered follow up as per the 72 hour pathway. This will allow for more robust risk management and coping strategies to be formulated in line with the ALIS pathway. Service users who are signposted following an assessment are discussed within the MDT and recalled if required.

ALIS will take referrals via SPA (1.4) and respond within the agreed timescales and will be prioritised by the shift lead according to need and identified risks. ALIS assessments can take place in the service user’s home or other identified location.

An ALIS assessment will include

 A comprehensive bio-psycho-social needs assessment including current and historical clinical signs, symptoms and severity of any mental health problems using standardised documentation.

 Assessment of risk, risk formulation and management plan.

 Service user consent to ALIS input and explanation regarding bounds of confidentiality.

 Identifying and discussing the factors contributing to the crisis, social stressors etc.

 Robustness of current support networks, identification of any dependants and their needs.

 With service user permission, carer and family views.

 The use of evidence based assessment tools, e.g. PHQ9, GAD7, PSYRATS, ACE-R or MMSE in line with the mental health service pathway assessment tool guidelines.

17  Liaison with IAPTUS (Improving Access to Psychological Therapies).

 Liaison with Memory Services.

 Case formulation and completion of care plan.

 Brief solution focused psychological therapy.

 Heath promotion, where appropriate, in relation to smoking, alcohol and illicit substance use.

 Pharmacological treatment initiation.

 Practical problem solving.

 Crisis and contingency planning and safety plan.

 GP liaison.

It is acknowledged that, on occasions, the nature of the service user presentation or identification of needs may make further assessment session(s) necessary. Therefore ALIS will have the option of offering further follow up appointments within the 72 hour period of their involvement to provide ongoing more detailed assessment. First presentation into mental health services, service users whose overdose or DSH requires medical treatment and those who present with increasing frequency will automatically be placed on the ALIS 72 hour pathway. Once placed on the pathway service users will be seen daily by a qualified practitioner.

ALIS will provide brief intervention work during this period and transfer into home treatment team if further intervention is required. Where ongoing care is needed, practitioners will refer or signpost on seamlessly to specialist, 3rd sector, or primary care following identified clinical pathway clusters.

There is a standard requirement when a Mental Health Act Assessment is called that as part of an integrated team approach, a member of the ALIS should attend the assessment to act in their role as gatekeepers to inpatient beds and support the assessment in relation to alternatives to hospital admissions wherever appropriate.

18 Following the initial assessment, all referrals and assessments will be discussed and recorded as part of the wider multi- disciplinary team, and in particular, with the Responsible Clinician to ensure enhanced decision making and regular clinical supervision.

2.2 Integrated approach with AMHPS

It is expected that there will be close working with AMHP in relation to Mental Health Act assessments and complex cases.

When there is an AMHP available in the ALIS/HTS then this person can be part of the assessing team and co-ordinate the Mental Health Act assessment if staffing allows for this to happen.

If possible then the AMHPs should be included in the MDT’s within all areas, this will enhance the MDT discussion

There is a standard requirement when a Mental Health Act Assessment is called that as part of an integrated team approach, a member of the ALIS should attend the assessment to act in their role as gatekeepers to inpatient beds and support the assessment in relation to alternatives to hospital admissions wherever appropriate

Where individuals are detained by police for assessment under Section 136 Mental Health Act designated places of safety are available throughout the County, it will be the joint responsibility of inpatient staff/ALIS/HT to provide support to the individual.

2.3 Gatekeeping for admission to hospital

ALIS will seek to avoid the need for hospital admission where care can be delivered safely and effectively elsewhere. Where the need for an admission is identified one of two pathways will be followed, informal admission or detention under the Mental Health Act, the ALIS shift coordinator will identify a hospital bed as close to home as possible and will liaise with both inpatient staff to ensure early engagement and seamless hand over of care. ALIS will also alert Home Treatment staff of all admissions to ensure there is whole system joined up working.

19 The ALIS shift coordinator will remain the gatekeeper of beds for the local Acute Mental Health admission units for the duration of the shift with any requests for beds being discussed and arranged via the ALIS shift coordinator. Requests for a bed will only be accepted by ALIS practitioners and Home Treatment Service practitioners although if there are any significant queries or difficulties, the ALIS shift coordinator may refer to the local Consultant Psychiatrist or bed manager for advice. The ALIS practitioner can look for a bed using the mental health dashboard and use this to identify the most appropriate bed.

2.4 Handover

ALIS will handover on a daily basis between shifts in relation to service users that have been assessed and the ongoing plan for the next 72 hours for those individuals that have been placed on 72 hour pathway. The ALIS practitioners will document in the record care or agreed documentation for each service user they are discussing as part of their handover and this will be filled in the service user’s record of care.

Assessment outcomes should clearly state what specific mental health services have been offered to the service user with a clinical rationale including risk formulation and management plan.

2.5 Transfers from ALIS to HT

ALIS may offer up to a 72 hours assessment period. There will be occasions when service users do require an extended period of assessment or further support. This will be for a period of short term intervention to bolster skills and coping strategies. Service users will receive a daily face to face appointment over the 72 hour pathway with a qualified practitioner

Transfer into home treatment comprises of the following:

 Handover of care plan indicating the goals for home treatment

 Risk assessment, formulation and management plan using GRIST

 HoNoS

20 Once this has been completed then the ALIS practitioner will complete the relevant documentation and electronic systems to enable the service user to be discharged from the ALIS caseload.

3. HOME TREATMENT SERVICE

3.1 Definition of Service

The Home Treatment Service (HTS) is a dedicated service within Urgent Care provided by CPFT. The service is designed to:

 Provide intensive HT for people with mental health needs to prevent further deterioration in their illness,

 Avoid inpatient admissions

 To support early discharges from hospital where appropriate.

 Work intensively with service users and carers for up to six weeks, although this is based on individual needs

All teams operate 7 days a week 24 hours a day. Telephone support for service users and carers will be the main intervention provided after midnight.

3.2 Home Treatment Referrals

Referrals will be received from CMHT, inpatient wards and ALIS, through SPA. The referrer will have completed a face to face mental health and risk assessment with the service user within the previous 24 hours and the care plan, crisis contingency plan and risk management plan will be provided. The Team will then provide the referring practitioner with a time and date for a face to face contact with the service user.

21 The care coordinator will

 Remain actively involved with the service user throughout the duration of time the service user is receiving additional support from the HT.

 Agree their involvement

 Attend a joint weekly review with the HTS as part of the service users care plan.

 Arrange for the duty worker to attend from the CMHT on their behalf if they are not available

 Make contact with both the service user and the ward within 72 hours if admitted to an inpatient facility

 Ensure 48 hour/7 day follow up after discharge from an episode of inpatient care takes place.

 Following admissions HTS will be involved in the acute admission pathway and will support early discharge agreed within the MDT

In line with the CPFT never event procedures, where a service user is to be referred on to another part of the mental health commissioned service provided by CPFT on discharge from Home Treatment Service, the team will maintain contact with the service user until there has been an allocation of a worker made by the receiving team.

3.3 Lead Practitioner

Each service user open to Home treatment will have a nominated named practitioner. They will be responsible for ensuring that the service user’s care is of good quality, coordinated and well led. They will also ensure that all paper work relating to their service users care is comprehensively completed

3.4 Facilitating early discharge

22 The role of the home treatment team is to facilitate early discharge from the inpatient units. A member of the home treatment team will interface into the acute admission pathway (AAP) meetings on the wards daily to discuss discharge planning for the service users.

3.4 Assessment and Intervention

The team has a wide range of skills and experience to draw on from within its multi-disciplinary staff group. This allows the provision of a broad range of evidence based interventions,

The team will ensure ongoing risk assessment is completed, including risk formulation and a management plan in conjunction with the service user and carer (subject to the agreement of the service user). The team will provide ongoing assessment of bio-psycho-social needs to optimise quality of life which will be planned with the service user. The team will focus on delivering:

 Assessment of risk and management plan.

 Robustness of current support networks, identification of any dependants and their needs.

 The use of evidence based assessment tools, e.g. PHQ9, GAD7, PSYRATS, ACE-R or MMSE in line with the mental health service pathway assessment tool guidelines.

 Liaison with IAPTUS (Improving Access to Psychological Therapies).

 Liaison with Memory Services.

 Case formulation and completion of care plan.

 Heath promotion, where appropriate, in relation to smoking, alcohol and illicit substance use.

 GP liaison.

 Safeguarding referrals.

23  Signposting to third sector and voluntary organisations where appropriate

 Referral on to primary, secondary or tertiary care with a robust plan in place.

 Carers assessment

 Identifying and discussing the factors contributing to the current deterioration in mental state.

 Brief psychological interventions

 On-going monitoring/assessment of mental state

 Stress/anxiety management

 Promotion of Social inclusion

 Practical problem solving.

 Advice and support in terms of daily living skills

 Medication management. Pharmacological treatment initiation and review.

 Working towards a diagnosis.

 Systemic support to individual, family, carers ensuring involvement of family and carers in the planning and evaluation of care with the service user’s agreement. Service user confidentiality will remain the priority of all practitioners until such time it is deemed unsafe for the individual or others.

 Frequent contact with service users as agreed within the care plan. This includes face to face contacts and also telephone contact, graduating towards discharge.

 Education about mental health.

 Support for the care coordinator in optimising care provision

24  Supplementing a relapse prevention/crisis plan and robust contingency planning with the care coordinator, service user and family/carer.

 Good communication with other key agencies and services.

 Monitoring and evaluating outcomes of the service.

 Referral on to alternative services where need is identified.

 Referral for carers for an assessment of their needs in accordance with the Carer’s Act Advocacy Safeguarding planning and referral.

 HTS will promote individuals’ independence and maximise resilience

Care planning will be led by a lead practitioner, but will require a whole team approach facilitated by discussion and agreement. Care planning will use the principles of CPA and where appropriate, S117 aftercare.

The Care plan and GRIST will be reviewed at least weekly as a minimum standard by the Multi-Disciplinary Team. Care planning will require the active involvement of the service user, taking account of the views, input and concerns of family/carers. Care planning involves actively planning for the discharge from HTS at an early stage in the process and will be agreed by all professionals involved.

Relapse prevention. The team will work with service users and their carers and other support services to identify early warning signs and strategies for managing early stages of relapse recording this in service users’ records.

3.5 Discharge planning

Prior to withdrawal from HTS the team should ensure, in conjunction with the care coordinator (if allocated) that they will have had regular reviews and a discharge planning meeting prior to closure. Agreement for discharge from HTS will be in discussion with all professionals involved and a date agreed to close the case Discharge from the HTS will be discussed at the point of assessment/entry to the service. Discharge arrangements will be planned wherever possible in discussion with the service user. Discharge will either involve continuation of care from

25 CMHTs; or in some instances successful resolution of the person’s mental health difficulties may result in transfer of care back to primary care services including first step (following the agreed pathway) or other 3rd sector providers.

A qualified practitioner is expected to ensure that:

 Discharge is to be discussed as part of the MDT/clinical review meeting, recorded clearly in the record of care.

 A pre-discharge meeting takes place with the service user and carer if appropriate

 A crisis contingency plan is agreed with the service user and carers.

 An updated risk assessment is completed and management plan, this should be shared with the GP and care coordinator if allocated.

 Any ongoing contact within CPFT is clarified and the service user is aware of this.

 A patient experience questionnaire will be taken out at the pre discharge meeting.

A discharge summary will be given to the service user and faxed to the General Practitioner on the day of discharge or pre discharge meeting. A discharge letter must be completed within 5 working days with the original copy placed in the post and copied to the service users and GP.

26 Appendix 1