A framework for community based mental health services 8 th October 2008 Mervyn Morris Professor of Community Mental Health Professor II, U.C. Buskerud,

A framework for community A framework for community

based mental health servicesbased mental health services

88thth October 2008 October 2008

Mervyn MorrisMervyn MorrisProfessor of Community Mental HealthProfessor of Community Mental Health

Professor II, U.C. Buskerud, NorwayProfessor II, U.C. Buskerud, NorwayDirector, Centre for Community Mental Director, Centre for Community Mental

HealthHealthBirmingham City UniversityBirmingham City University

Developing a frameworkDeveloping a framework

Development of effective individual community Development of effective individual community teams requires consideration of the impact on the teams requires consideration of the impact on the whole system.whole system.

In Birmingham community team development was In Birmingham community team development was part of total service re-design; re-organisation of part of total service re-design; re-organisation of services and re-allocation of resources.services and re-allocation of resources.

There was an intentional shift of the centre of the There was an intentional shift of the centre of the service away from hospital into the community. service away from hospital into the community. This has had a significant impact on the function of This has had a significant impact on the function of the hospital too.the hospital too.


Shift focus from hospital to community:Shift focus from hospital to community: Functionalise community in same way that Functionalise community in same way that

hospital was/is ‘functionalised’, i.e. separate hospital was/is ‘functionalised’, i.e. separate specialised service or team.specialised service or team.

Emphasis on multi-disciplinary team working; Emphasis on multi-disciplinary team working; social care integratedsocial care integrated

Identifying clear roles and boundaries between Identifying clear roles and boundaries between functions i.e. teamsfunctions i.e. teams


Some key issues:Some key issues:

A system of filters and gateways A system of filters and gateways

FidelityFidelity

Staff trainingStaff training

HOSPITAL

Continuing needs:REHABILITATION wardsLONG STAY wards

ACUTE/ admission wards

Out-patients department

COMMUNITYPRIMARY CARE & AFTERCARE SERVICECounselling & Depot injectionsPsychotherapy Residential care support

Once upon a time..Once upon a time..

Why develop community based Why develop community based

mental health services?mental health services? De-institutionalisationDe-institutionalisation New Models of Community Mental New Models of Community Mental

HealthHealth Human Rights and ValuesHuman Rights and Values National Mental Health PolicyNational Mental Health Policy Expanding remit of mental healthExpanding remit of mental health Consumer/ User/ Carer ViewsConsumer/ User/ Carer Views

The ‘functionalised’ community The ‘functionalised’ community modelmodel

Primary Care LiaisonPrimary Care Liaison

Short term Care: Short term Care: Crisis/ Home Treatment ServiceCrisis/ Home Treatment ServiceResidential Services; hospital etc.Residential Services; hospital etc.

Continuing Care:Continuing Care:Rehabilitation/ Recovery Rehabilitation/ Recovery Assertive Outreach ServiceAssertive Outreach Service

Community PRIMARY CARE

LIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH

RECOVERY AND REHABILITATION

CommunityHOME

TREATMENT

Residential based care: Hospital Beds, Day services, Crisis Homes,

Functional Functional mapmap

Community PRIMARY CARELIAISON TEAMS

CommunityCONTINUING

NEEDS TEAMS;

ASSERTIVE OUTREACH TEAMS

Recovery & Rehabilitation Teams

CommunityHOME

TREATMENTTEAMS


Model 1Model 1

COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM


PRIMARY CARE TEAM Model 2Model 2

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT


NOT the whole NOT the whole picture..picture..

EARLY INTERVENTION

SERVICE

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



EARLY INTERVENTION

SERVICE

SPECIALIST SERVICES

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



EARLY INTERVENTION

SERVICE

SPECIALIST SERVICES

DUAL DIAGNOSIS

SERVICE

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



EARLY INTERVENTION

SERVICE

SPECIALIST SERVICES

DUAL DIAGNOSIS

SERVICE

OLDER ADULT

SERVICES

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



EARLY INTERVENTION

SERVICE

SPECIALIST SERVICES

DUAL DIAGNOSIS

SERVICE

OLDER ADULT

SERVICES

CHILDRENS SERVICES

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



EARLY INTERVENTION

SERVICE

SPECIALIST SERVICES

DUAL DIAGNOSIS

SERVICE

OLDER ADULT

SERVICES

CHILDRENS SERVICES SOCIAL

SERVICES

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



EARLY INTERVENTION

SERVICE

SPECIALIST SERVICES

DUAL DIAGNOSIS

SERVICE

OLDER ADULT

SERVICES

CHILDRENS SERVICES SOCIAL

SERVICES

ETCETERA!

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT




Interface between primary care and Interface between primary care and specialist servicespecialist service

Gateway to specialist servicesGateway to specialist services Manage all new referrals from Primary Manage all new referrals from Primary

CareCare Key workers with variable case loadKey workers with variable case load Clinics, groups, home based Clinics, groups, home based

interventionintervention Multidisciplinary teamMultidisciplinary team


Working hours serviceWorking hours service Varies across city in terms of delivery Varies across city in terms of delivery

because;because; Integration of a continuing needs service: Integration of a continuing needs service:

‘Community Mental Health Teams’‘Community Mental Health Teams’ Some Teams have a base with a day hospital-like Some Teams have a base with a day hospital-like

facilityfacility GP’s prefer to provide part of a service themselves GP’s prefer to provide part of a service themselves

e.g. health promotione.g. health promotion Some GP’s commission a service within their Some GP’s commission a service within their

surgeriessurgeries Different development of Gateway workersDifferent development of Gateway workers

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


HOME TREATMENT



Home Treatment and Crisis Home Treatment and Crisis ResolutionResolution

‘‘Acute’ psychiatric care at homeAcute’ psychiatric care at home Mobile, 24 hour 7 days a week serviceMobile, 24 hour 7 days a week service Crisis resolution Crisis resolution andand Home Treatment Home Treatment Access to hospital bedsAccess to hospital beds Alternative to psychiatric Alternative to psychiatric

hospitalisationhospitalisation Multidisciplinary teamMultidisciplinary team Shared caseload ≤ 2:1Shared caseload ≤ 2:1 Utilise home and community resourcesUtilise home and community resources

Crisis Resolution/ Home Crisis Resolution/ Home Treatment (CR/HT)Treatment (CR/HT)

Rapid response following referralRapid response following referral Assertive approach to engagementAssertive approach to engagement Intensive intervention and support in the Intensive intervention and support in the

early stages of the crisisearly stages of the crisis Active involvement of the service user, Active involvement of the service user,

family and carersfamily and carers Time-limited intervention that has Time-limited intervention that has

sufficient flexibility to respond to differing sufficient flexibility to respond to differing service user needsservice user needs

Learning from the crisisLearning from the crisis

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



COMMUNITY MENTAL HEALTH TEAMPrimary Care Continuing Need:Liaison Rehab and Recovery

CONTINUING NEED

ASSERTIVE OUTREACH TEAM

HOME TREATMENT

TEAM


PRIMARY CARE TEAM Model 2Model 2

Rehabilitation and Recovery Rehabilitation and Recovery (Community Mental Health (Community Mental Health

Teams)Teams) People predominantly with ‘severe/ People predominantly with ‘severe/

enduring’ illness experienceenduring’ illness experience Complex social and health care needsComplex social and health care needs Long term service useLong term service use Need for Need for community basedcommunity based support support Recovery and social integrationRecovery and social integration Individual case management but Individual case management but

access to team resourcesaccess to team resources

PRIMARY CARELIAISON

CommunityCONTINUING

NEEDS

ASSERTIVE OUTREACH


CommunityHOME

TREATMENT



Assertive OutreachAssertive Outreach

Team based approach with key Team based approach with key workerworker

Team responsible for meeting all Team responsible for meeting all needsneeds

Assistance in obtaining basic needsAssistance in obtaining basic needs Primary goal of improved client Primary goal of improved client

functioningfunctioning Assistance with symptom Assistance with symptom

managementmanagement

Assertive OutreachAssertive Outreach

One team member is care One team member is care coordinatorcoordinator

Smaller case load ( ≤ 15:1)Smaller case load ( ≤ 15:1) Treatment is individualisedTreatment is individualised Services provided “out of office”Services provided “out of office” Assertive “can do” approachAssertive “can do” approach

Maintaining a frameworkMaintaining a framework

Key issues:Key issues:

A system of filters and gateways A system of filters and gateways

FidelityFidelity

Early and later development problemsEarly and later development problems

Staff trainingStaff training

FinFin

[email protected]@bcu.ac.uk

Documents

A framework for community based mental health services 8 th October 2008 Mervyn Morris Professor of Community Mental Health Professor II, U.C. Buskerud,