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Acute Mental Health Care PathwayOctober 2018
3
Contents
Section Contents Page
1 Foreword and Equality Statement 4
Acknowledgements 5
2 Introduction 6-7
3 Principles and Values of Acute Mental Health Care 8-9
4 Key Service Areas of the Acute Care Pathway 10-11
5 Acute Mental Health Care Pathway Standards 12
6 Acute Mental Health Care & Treatment Options 13-14
7 Environment Standards 15-17
8 Equality Considerations 18-19
9 The Acute Mental Health Care Pathway at a Glance 20
10 Acute Mental Health Care Pathway Stages 21-33
11 Supporting Resources 34
12 Glossary 35
13 Bibliography 36
14 Appendix 1 - Theraputic Inteventions Described 37
4
Foreword
We have developed this Acute Care Pathway, thereafter referred to as the Pathway, for patients who require acute mental health care and support. The Pathway recognises that all treatment and care needs to be highly personalised and recovery orientated.
At the heart of this Pathway is the recognition that patients, whether they are using, supporting or providing a service, have a positive contribution to make.
Through the development and implementation of this Pathway we are confident that it will help to promote a genuine partnership approach in mental health services.
Equality Statement
In line with Section 75 of the Northern Ireland Act 1998, Acute Mental Health Services will be provided and available to all irrespective of gender, ethnicity, political opinion, religious belief, disability, age, sexual orientation, dependant and marital status.
Acute Mental Health Services have a duty to each and every individual that they serve and must respect and protect their human rights. At the same time, Acute Mental Health Services also have a wide social duty to promote equality through the care they provide and in the way they provide care. This includes addressing the needs of those groups or sections of society who may be experiencing inequalities in health and wellbeing outcomes.
Alternative Formats
This report can also be made available in alternative formats: large print, computer disk, Braille, audio tape or translation for anyone not fluent in English. Please contact the Communications Office at the Health and Social Care Board www.hscboard.hscni.net.
Foreword & Equality Statement
5Acute Mental Health Care Pathway - Northern Ireland
Acknowledgements
This Care Pathway has been jointly developed by experts by experience, (people with lived experience, family members, partners, friends and/ or advocates for people with mental health needs) and professionals involved in leading and delivering care, reflecting a commitment to supporting a culture of partnership, co-working and co-production.
Acknowledgements
Adrian Cluett (SHSCT)
Dr Ann McDonnell (BHSCT)
Agnes Dee (BHSCT)
Damien Brannigan (SEHSCT)
Anne Cunningham (CAUSE)
Briege Quinn (PHA)
Brian McGarvey (WHSCT)
Edwina Agahi (CAUSE)
Cahal McKervey (BHSCT)
Muriel McCleery (SEHSCT)
Denise Martin (PHA)
Dr Neta Chada (SHSCT)
Eithne Darragh (HSCB)
Christine Bateson (NHSCT)
Kiera Lavery (SHSCT)
Emma Cunningham (SEHSCT)
Louise Hall (SHSCT)
Dr Stephen Bergin (PHA)
Marilyn Grant (NHSCT)
Uzma Huda (NHSCT)
Martina McCafferty (HSCB)
Patrick Convery (RQIA)
The Project Team would also like to acknowledge and thank the wide number of people who responded to the consultation exercises as the pathway was developed. The feedback provided was a very helpful contribution in creating a pathway that enables everyone to have the very best care and a positive experience of emotional and mental health services.
The Project Team
6
Introduction
The purpose of the Pathway is to provide guidance on the key components of acute care to be delivered, to enhance the quality of service experience and promote consistency of service delivery across Northern Ireland. The document has drawn from the range of documents compiled by the Joint Commissioning Panel for Mental Health http://www.jcpmh.info/
The Pathway describes a whole systems approach to acute mental health care, outlining the services that are required to deliver an acute mental health service which is fit for purpose in terms of quality and governance.
The Pathway should be read in conjunction with the You In Mind Regional Mental Health Care Pathway launched in October 2014 which is underpinned by the ethos of “recovery”, and is guided by the values set out in ‘NICE 136: Improving the Experience of People Using Adult Mental Health Services’.
Acute mental health services provide intensive treatment for those patients who are most acutely unwell and vulnerable.
The Pathway/Services will: -
• meet the mental health needs of those patients who cannot be supported by primary care and specialist community-based services;
• include crisis resolution and home treatment services, unscheduled care, acute day services and inpatient services;
• include a range of community-based supports that may be commissioned to complement treatment at home or in hospital.
The Pathway has been co-produced by people with lived experience, family members, partners, friends and/or advocates for people with mental health needs and professionals involved in commissioning and providing care. Co-production acknowledges that people with lived experience are often best placed to advise on what support and services will make a positive difference to their lives. It is underpinned by the key values of ownership, openness and honesty.
The Pathway outlines the journey that patients make from referral to discharge from acute services. It refers to the interlinked services and agencies working together to support patient and carer needs and achieve desired outcomes.
2. Introduction
Step 1: Self directed help and health and wellbeing services.
Step 2: Primary Care Talking Therapies.
Step 3: Specialist Community Mental Health Services.
Step 4: Highly Specialist Condition Specific Mental Health Services.
Step 5: High Intensity Mental Health Services.
Support at this level usually involves responding to stress and mild emotional difficulties which can be resolved through making recovery focused lifestyle adjustments and adopting new problem solving and coping strategies.
Support at this level usually involves responding to mental health and emotional difficulties such as anxiety and depression. Recovery focused support involves a combination of talking therapies and lifestyle advice.
Support at this level usually involves responding to mental health problems which are adversely affecting the quality of personal / daily and/ or family/ occupational life. Recovery focused support and treatment will involve a combination of psychological therapies and/ or drug therapies.
Support at this level usually involves providing care in response to complex/ specific mental health needs. Care at this step involves the delivery of specialist programmes of recovery focused support and treatment delivered by a range of mental health specialists.
Support at this level is usually provided in response to mental health needs, including adopting new problem solving coping strategies, which involves the delivery of intensive recovery focused support and treatment provided at home or in hospital.
The Pathway specifically focuses on Steps 4 and 5 of the Stepped Care Model set out in the You in Mind Regional Mental Health Care Pathway (2014), as shown below:
7Acute Mental Health Care Pathway - Northern Ireland
8
3.0
The delivery of acute mental health inpatient care is underpinned by a range of principles and values which are respectful of patients’ human rights, including the rights to receive services that offer:
• Quality and safety;
• Privacy and dignity;
• Person centred care;
• Opportunities for collaborative working with families/carers;
• Accessibility;
• Least restrictive option on an individual’s liberty;
• Choice.
3.1
Patient Quality and Safety
As acute mental health care is a particularly high risk area, of mental health care it is essential that services are appropriately resourced, based on evidence and regionally and nationally agreed standards. This will lead to a timely response, sufficiently intensive support, safer environments and seamless care.
3.2
Person Centred Care
When a patient requires mental health acute care they have high levels of need and are often in crisis, anxious and vulnerable. In many cases patients will be at risk of self-harm or suicide.
Ensuring the mental health care needs are identified and addressed is critical to the patient’s recovery and their future engagement with mental health services.
3. Principles and Values of Acute Mental Health Care
9Acute Mental Health Care Pathway - Northern Ireland
3.3
Collaborative Working
This Pathway recognises the triangle of care, the partnership between carers, patients and professionals in working towards recovery. It is acknowledged that family/partners/friends can contribute knowledge and information which may help identify early warning signs and which will positively impact on their loved ones’ wellbeing and personal safety.
This plays an important part in the Pathway in supporting improved outcomes for care planning and recovery. A carer’s understanding of their loved one and what is important to them can significantly enhance person-centred care planning and engagement with mental health professionals. It is essential that the role carers play is acknowledged with the provision of support for carers as an equal partner in care.
3.4
Good Communication
It is essential that there is clear communication between acute care teams and others involved in the care of people in both primary and secondary care, specifically: -
• Close liaison between inpatient, Home Treatment Team (HTT) and crisis teams;
• GPs/practices to be contacted within 24 hours (next working day) when someone is admitted acutely/seen by a crisis team/HTT and that they are again informed within 24 hours when someone is discharged with a current diagnosis and list of their current medication (more detailed discharge summaries can follow later);
• Close, proactive communication with community mental health services/care co-ordinators to ensure better care continuity and to facilitate the journey through the care Pathway;
• Good communication with any other agencies involved, for example Addictions Services/Eating Disorders/Forensic/ Public Protection/Social Services.
3.5
Patient Experience
As a partner in their care, patients can expect to be:
• Listened to, valued and understood
• Given meaningful information and explanation
• Encouraged and given time to recover
• Provided advocacy and peer support
• Given choice
• Supported to make decisions
• Encouraged to give feedback
10
4. Key Service Areas of Acute Care Pathway
4.1 Key Service Areas Explained
There are four key components of acute care in mental health:
i) Home treatment;
ii) In-patient services;
iii) Acute day services;
iv) Home treatment house / Crisis house.
• Home Treatment Team (HTT)
Provide treatment at home for those acutely unwell who would otherwise require hospital admission. The Team ‘gate-keeps’ (assesses the appropriateness) of inpatient admissions, and facilitates early supported discharges.
This is a multidisciplinary team that operates on a mobile basis 24 hours a day, 7 days a week.
The decision to admit to Home Treatment will be taken following a clinical assessment, including safety planning and patients need to be willing to engage with the service. HTTs have the capacity to visit patients in their own home daily, or more often based on assessed need. HTTs are multidisciplinary and may include mental health nursing, social work, occupational therapy, psychiatry, pharmacy, psychology, peer support, advocacy, etc.
• Inpatient Services
Provide a high standard of treatment and care in a safe and therapeutic setting for patients who have been assessed by HTTs as requiring hospital care usually due to the patient being assessed as being a serious risk to themselves or others and being unable to engage with treatment at home. Admissions are considered when this is essential for a person’s progress to recovery from the acute stage of their illness.
There are two types of inpatient service:
i. Acute inpatient wards Provide inpatient facilities for a broad range of psychiatric diagnoses for people who cannot safely receive their care in the community.
ii. Psychiatric intensive care units (PICUs) Provide high intensity nursing and medical care for patients whose illness means they cannot be safely cared for on an acute/open ward. Prior to being admitted to these wards, patients will have been assessed under the Mental Health Order (NI) 1986. PICU staff will also provide advice and support to staff caring for patients on acute wards reducing the need for patients to be admitted to PICU. They can be located at a stand-alone unit adjacent (co-located) to other mental health inpatient facilities or as a ward within a larger unit (integrated).
• Acute Day Services
These services provide an alternative to admission for people who are acutely unwell and are a means of facilitating early discharge and preventing re-admission. Acute day services may be provided as an integral element of an acute hospital unit or as a stand-alone facility and can be offered independently or as complementary to Home Treatment.
Acute day services offer a safe and supportive environment to allow staff to complete a full assessment and establish a Safety Plan. It provides a full therapeutic programme which aims to support the patient to resolve, manage and prevent future crisis. This is achieved through education, advice and supporting the patient to problem solve, develop positive coping skills and build resilience. Staff promote a healthy balanced lifestyle, optimise engagement in meaningful activities and assist in identifying and accessing appropriate community resources relevant to identified need.
• Home Treatment House/Crisis House/Crisis Beds
This is a small community facility with beds provided by a single Trust for its population, for patients who have been assessed as suitable for Home Treatment but are unable to remain at home. Reasons for being unable to stay at home may include breakdown in relationships with carers/family or having no carer in the home.
The unit may be staffed by mental health professionals or support staff and acute care will be provided by the HTT. This provision may also be used to support people making the transition from hospital to home.
The Home Treatment/Crisis House and similar approaches to providing respite or sanctuary outside of hospital has been developed alongside Crisis Resolution and Home Treatment Teams (CRHT) and hospital approaches. They have strong support from patient groups. These are community-based crisis/home treatment services that offer residential support
The community infrastructure including, community mental health services, specialist mental health teams (eg forensic, personality disorder services) early intervention services, drug and alcohol services, liaison services and supported housing are not part of this Pathway but are essential components of support for people with mental health needs. It is also acknowledged that there is a continuing need to focus on prevention, wellbeing and community services.
Depending on the local context, other services will interface with the acute care Pathway including prisons, courts, mental health liaison service to Emergency Departments, and other acute wards in general hospitals and primary care services.
11Acute Mental Health Care Pathway - Northern Ireland
12
5.1 Acute Care Services will have the following Standards:
• Intensive assessment and treatment of patients’ needs and strengths over 24 hours per day;
• A care model used and understood by all professionals and easily explained to patients and carers which delivers a full range of evidence-based approaches including pharmacological, physical health, psychological, occupational and social interventions which focus on the person’s recovery;
• Multi-disciplinary input that enables a bio-psychosocial approach to meeting the patient’s and family’s needs;
• On-going assessment and management of risk, which is a dynamic process that may fluctuate;
• A therapeutic environment to support engagement and recovery;
• Sanctuary for patients who are experiencing acute distress within the context of a mental illness;
• Sufficient staffing to ensure that evidence-based interventions are available when patients require them;
• Access to advocacy and peer support;
Acute Care Services will also adhere to the service standards set out in the You in Mind Regional Mental Health Care Pathway (2014). Specific standards for Acute Care Services include:
» A safer environment to commence treatment for patients, including detained patients. This may include restrictive practices and deprivation of liberty. There will be safeguards to ensure these are used only when necessary and employed appropriately;
» Good communication within acute care and with other mental health care teams and primary care;
» A recovery focus which is demonstrated by outcome measurement, demonstrating that services are increasing opportunities to build a life beyond illness, enhancing quality of life and wellbeing;
» Support and education for families and/or carers who may be dealing with acute illness;
» Evidenced patient and carer experience data and satisfaction;
» Information about the service for service users and carers.
5. Acute Mental Health Care Pathway Standards
6. Acute Mental Health Care & Treatment Options
13Acute Mental Health Care Pathway - Northern Ireland
6.1 Effective Care and Treatment in a Recovery Focused Environment
Based on the patient’s assessed needs they will be offered one or a combination of the care/treatment options. This will be either in an inpatient ward or home based treatment where the following may be required:
• A range of evidence-based interventions should be offered within acute care. They will be structured and focused on stabilisation and enhanced coping skills; including brief interventions (cognitive therapy, solution focused therapy, interpersonal therapy, interventions for drug and alcohol misuse, pharmacological interventions and relapse prevention);
• Opportunities for peer support;
• Access to appropriate therapies eg Occupational Therapy, assessments and activities;
• Social, physical and psycho-education for patients and carers;
• Carer support and assessment;
• Family interventions
The intervention offered will be guided by the patient’s level of functioning and the outcome of their psychological assessment and formulation.
Mental Health services will explain which option(s) are recommended for a patient’s recovery and they will explain the relevant National Institute Care Excellence (NICE) clinical guideline(s) being followed to meet the patient’s needs.
14
6.2 Involving Families
Family/carers will be provided with information to help them understand mental illness and treatment options, and, carer support assessments will be offered routinely. In addition, Trusts should aim to work towards implementing the Triangle of Care as outlined in the six key elements below. This is designed to achieve better collaboration and partnership with carers in the patient and carer’s journey through a typical acute episode.
The six key elements state that:
i. Carers and the essential role they play are identified at first contact or as soon as possible thereafter;
ii. Staff are ‘carer aware’ and trained in carer engagement strategies;
iii. Policy and practice protocols in relation to confidentiality and sharing information are in place;
iv. Defined post(s) responsible for carers are in place;
v. A carer introduction to the service and staff is available, with a relevant range of information across the acute care pathway;
vi. A range of carer support services are available.
6.3 Learning from Patient Experience
Trusts will be expected to measure the impact of care using the regionally agreed validated measurement framework and patient experience feedback. Trusts will report progress against clinically validated measurement tools via the Service Framework for Mental Health and Wellbeing reporting mechanism.
15Acute Mental Health Care Pathway - Northern Ireland
7. Environment Standards
7.1 Introduction
This section describes environmental standards that all acute mental health inpatient services within the Northern Ireland region should aspire to achieve in the design, maintenance and operational management of facilities, regardless of the degree of progress associated with the development of new purpose built wards. While the primary aim throughout the development of these standards has been enhancing safety and security, it is recognised that standards associated with safety and security are inextricably linked to standards that promote a positive therapeutic and recovery focused experience for patients and staff.
It is expected that these standards will influence the planning and design of acute inpatient facilities. They will enable regionally consistent and continuous monitoring to assist providers and commissioners in determining priorities and actions required to enhance the safety and therapeutic value of acute mental health inpatient environments.
7.2 The Standards
The Department of Health’s (2008) paper ‘Laying the Foundations’, which highlights specific requirements for inpatient mental health facilities including the environment of care that patients have the right to expect.
The document stresses that all new facilities should strive to:
• Improve the physical and mental wellbeing of patients, staff, carers and visitors;
• Improve individual patients’ recovery;
• Create an environment in which people can learn and be creative;
• Ensure services provide effective and efficient care and treatment;
• Provide care in a safe environment that is free from smoke, drug and alcohol abuse;
• Provide a ‘generous provision’ of circulation space to reduce a “pressure cooker” type atmosphere;
• Provide dedicated space for visiting children, located adjacent to the ward with sufficient playing materials;
• Improve links with local communities to reduce stigma and social exclusion;
• Improve the human rights of patients, staff, carers and visitors.
16
Acute Mental Health In-patient Service Standards should be co-located together, which serves a number of benefits including:
» Improving the standardisation and delivery of best practice;
» Reducing the need for patient transfers between disparately located wards;
» Improving access to inpatient care through better bed capacity management;
» Reducing the isolation of units and providing a more supportive environment to teams;
» Creating a more flexible and responsive service;
» Creating economies of scale that enable the concentration of resources.
They should be co-located with general acute services so that patients have optimum access to appropriate diagnostics, care and treatment for physical health problems.
Where they are not located on an acute site, there should be prompt support from other medical services (DoH, 2013) that should be explicitly outlined:
• Provide single en-suite bedrooms. Where this is not possible, male and female patients should be afforded separate accommodation for sleeping and washing, etc. These should be freely accessible from communal areas which are spacious and included sufficient:
» activity areas;
» quiet areas;
» family/child visiting room;
» fitness facilities;
» wide corridors;
» outside viewing areas;
» natural lighting;
» rooms suitable for assessing and de-escalating distressed or agitated patients.
• Should be co-located with the Trust’s Psychiatric Intensive Care Unit (PICU);
17Acute Mental Health Care Pathway - Northern Ireland
• Will conduct a general risk assessment every six months, or more regularly according to the level of risk that arises. The general risk assessment will consider the risks posed to patients, staff and members of the public through: violence and aggression; self-harm and suicide; absconding; misuse of drugs and/or alcohol. In carrying out these assessments, control measures and further actions required to address identified risks need to be recorded and implemented.
• Will conduct a ligature risk assessment every six months, or more regularly according to the level of risk that arises. In carrying out this assessment, control measures and further actions required to address identified ligature points need to be recorded and addressed. This applies to the risks posed by en-suite doors, which have been used as a ligature point in a number of reported incidents across the region.
• Have in place entry and egress control measures that are governed by an appropriate protocol.
• Have access to Trust security teams to support the management of violence and/or potential violence. Where this is not the case, arrangements for dealing with a security incident should be explicitly set out eg involving the PSNI.
• Provide a patient call system.
• Provide a staff personal alarm system, with sufficient numbers of alarms to accommodate all relevant staff. Each service should have procedures in place to govern the response to alarm activation and the testing of equipment.
• Have good lines of sight that allow staff to easily and unobtrusively observe all areas of the ward.
• Have access to suitable levels of CCTV coverage, including outdoor spaces, as per Trust policy.
• Have established minimum nurse staffing levels to maintain safety and provide an appropriately therapeutic environment. Each service should have a protocol in place to govern what will happen in the event of staffing levels falling below the established minimum standard.
• Do not allow direct access to bedroom windows from outside (being careful to account for privacy issues so that internal courtyards aren’t looking directly into bedrooms etc).
• Where possible allow patients to control factors such as bedroom temperature and lighting, where possible.
• Contain suitable acoustics to reduce the unwanted effects of echo or noise travel.
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8. Equality Considerations
Acute mental health care needs to be accessible and appropriate to all those who may need it. Specifically, services must promote equality in accessibility to mental health services.
For example, adjustments may be needed to enable a disabled person to stay in an acute unit, access psychological therapies or participate in therapeutic activities and language barriers and other communication issues may need to be addressed. Cultural awareness in constructing care plans and providing services may also be needed, including for example:
• The person may live with family members, or may need to have support from family and friends both inside and outside the acute unit to reduce fear and isolation;
• Food requirements, dress requirements, a place and time to pray if needed, should all be discussed with the person and considered throughout inpatient care;
• In organising therapeutic activities staff should be mindful that individuals may not wish to drink, mix with the opposite gender in close proximity, or may have certain beliefs or values which would be compromised if they were forced to carry out specific activities.
Actions that promote equality and cultural awareness include:
i. Employing interpreters or staff with various language skills;
ii. Providing information in various languages and formats, including for example how the service is organised, processes involved in hospital admission, medication requirements, and the right to advocacy;
iii. Training staff in different groups’ needs and requirements;
iv. Displaying policies and accredited standards in wards and other premises to confirm that discrimination, abuse or violence will not be tolerated towards any group;
v. Openly recruiting staff from all sections of society;
vi. Working with external agencies and charities such as BME charities, lesbian, gay, bisexual and transgender groups, disability groups and religious and spiritual organisations, to ensure the needs of people with mental health problems are being met in the best way possible;
19Acute Mental Health Care Pathway - Northern Ireland
vii. Recording and measuring objectives and outcomes of services, including service user/patient satisfaction, and by protected characteristics under Section 75 of the Northern Ireland Act 1998, so that inequalities can be addressed;
viii. Ensuring access to advocacy and support to make complaints;
ix. Considering patients’ needs holistically, including the impact of race or religion on where people live, their community, places they go to, people they see, and what they discuss with others in regards to their mental health;
x. Taking account of the cultural environment to which patients return when discharged, and the impact on them and their family after being in an acute unit.
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9. The Acute Mental Health Care Pathway at a Glance
In-p
atie
nt a
nd
Hom
e Tr
eatm
ent
serv
ices
pro
vide
in
divi
dual
ised
w
hole
per
son
care
that
pr
omot
es
reco
very
and
in
clus
ion.
1.
Ass
essm
ent a
nd P
lan
to a
dmit
or p
rovi
de H
ome
Trea
tmen
t
2.
Pre-
adm
issi
on fo
r In
-pat
ient
/Hom
e Tr
eatm
ent
Pr
epar
atio
n fo
r adm
issi
on
3.
On
adm
issi
on fo
r In
-Pat
ient
/Hom
e Tr
eatm
ent (
with
in fi
rst 4
hour
s) I
nitia
l ass
essm
ent a
nd c
are
plan
4.
Adm
issi
on fo
r In
-Pat
ient
/Hom
e tr
eatm
ent (
with
in fi
rst 2
4
ho
urs)
Orie
ntat
ion/
info
rmat
ion
givi
ng
5.
Com
preh
ensi
ve a
sses
smen
t and
form
ulat
ion
(th
e fir
st 7
2 ho
urs)
6.
Com
preh
ensi
ve A
sses
smen
ts fo
r In
-pat
ient
/ H
ome
trea
tmen
t
(with
in fi
rst w
eek)
7.
The
Reco
very
Pro
cess
- W
eekl
y cy
cle
8.
Dis
char
ge -
Pla
nnin
g an
d D
isch
arge
Overview of In-patient/Home Treatment pathway at a Glance
21
10. Adult Mental Health Acute Care Pathway Stages - Inpatient
Stage 1In-patient Assessment and Initial Formulation
Pers
on c
omes
to th
e at
tent
ion
fo a
cute
car
e pa
thw
ay-
Def
ined
as
poss
ibly
requ
iring
adm
issi
on in
to a
n ac
ute
adm
issi
on w
ard
in n
ear f
utur
e -
In C
risis
Tele
phon
e ca
ll -
Refe
rral
- In
itial
resp
onse
and
col
lect
ion
of d
ata
- El
ectr
onic
refe
rral
form
com
plet
ed
Not
kno
wn
to s
ervi
ces
Acc
ept f
or H
ome
Trea
tmen
t
Sign
post
to o
ther
ser
vice
-
Reas
ons
for r
efer
ral
-
Up
to d
ate
risk
asse
ssm
ent
-
Back
grou
nd in
form
atio
n-
C
ultu
ral,
relig
ious
and
lang
uage
in
form
atio
n fr
om re
ferr
er
Iden
tify
nam
ed C
RHT
wor
ker a
nd te
am
mem
bers
prim
arily
del
iver
ing
care
pla
n
Dev
elop
par
tner
ship
s w
ith o
ther
ag
enci
es/s
ervi
ces
Cris
is H
ouse
s et
c
Dev
elop
par
tner
ship
s w
ith o
ther
ag
enci
es/s
ervi
ces
Cris
is H
ouse
s et
c
Go
to S
tage
2A
dmis
sion
Che
ckTr
ust d
ata
syst
em fo
r all
rele
vant
info
rmat
ion
Kno
wn
to s
ervi
ces
Acu
te
asse
ssm
ent
and
Hom
eTr
eatm
ent
Requ
est m
edic
atio
n hi
stor
y fr
om re
ferr
er/N
IEC
R
Out
com
e of
scr
eeni
ng/T
riage
Out
com
e of
initi
al a
sses
smen
t
Ass
essm
ent
Not
app
ropr
iate
for a
cute
ass
essm
ent
-
Cla
rify
men
tal s
tate
-
Cla
rify
capa
city
for d
ecis
ion
-
Supp
ort a
t hom
e
Det
aine
d ad
mis
sion
Volu
ntar
y ad
mis
sion
Stage 2In-patient Pre-admission preparation
Key
Obj
ectiv
es
Patie
nts
shou
ld b
e tr
eate
d in
the
leas
t res
tric
ted
envi
ronm
ent w
hich
is
cons
iste
nt w
ith th
eir c
linic
al
need
s.
Inpa
tient
adm
issi
ons
and
pres
sure
on
beds
sho
uld
be re
duce
d.
Equi
ty o
f acc
ess
to a
n al
tern
ativ
e to
adm
issi
on fo
r pa
tient
s an
d fa
mili
es m
ust
be e
nsur
ed.
Pre-
adm
issi
on c
heck
list (
exac
t act
ions
will
var
yw
ith c
ircum
stan
ces
Go
to S
tage
3A
dmis
sion
Volu
ntar
y ad
mis
sion
Dec
isio
n to
adm
it
Det
aine
d ad
mis
sion
und
er
the
Men
tal H
ealth
Ord
er
Mak
e pa
tient
/rel
ativ
es a
war
e of
ch
ild v
isiti
ng a
rran
gem
ents
and
m
ake
a ca
se n
ote
entr
y fo
r MD
T Re
view
to a
sses
s ris
ks/
safe
guar
ding
the
child
. (In
form
the
Hea
lth V
isito
r of a
ny c
hild
und
er
the
age
of 5
yea
rs o
ld.)
Cla
rify
adm
issi
on a
rran
gem
ents
ie tr
ansp
ort,
time
of a
rriv
al, e
scor
t etc
.
Ensu
re n
o im
med
iate
sa
fegu
ardi
ng is
sues
, jo
intly
with
soc
ial
serv
ices
if n
eces
sary
Info
rm c
arer
s of
adm
issi
on (i
f app
ropr
iate
)-
Info
rmat
ion
abou
t hos
pita
l-
Tele
phon
e co
ntac
ts-
Arr
ange
men
ts fo
r vis
iting
Sour
ce a
ccom
mod
atio
n, A
dvis
e po
licy
for n
on-s
mok
ing,
mob
ile
phon
es, s
afek
eepi
ng m
onie
s. O
btai
n in
form
atio
n on
reco
rds,
car
e pl
ans,
risk
ass
essm
ent,
reas
ons
for a
dmis
sion
Is th
e pa
tient
re
spon
sibl
e fo
r ot
hers
, e.g
. de
pend
ent c
hild
ren?
22
Stage 3In-patient Admission
Commence normally within first 4 hours
Patie
nt a
ccep
ted
for
adm
issi
on
0 -
4 h
ours
Orie
ntat
ion
/ in
form
atio
n gi
ving
Take
app
ropr
iate
ste
ps to
ens
ure
safe
ty a
s a
prio
rity
from
kno
wn
risks
with
app
ropr
iate
obs
erva
tion
and
inte
rven
tions
from
arr
ival
Show
the
patie
nt a
roun
d th
e w
ard,
exp
lain
ing
the
fire
drill
, any
sig
nific
ant i
ssue
s of
saf
ety
and
an e
xpla
natio
n of
th
e ne
ed fo
r a lo
cked
doo
r or a
ny o
ther
hin
dran
ces
to c
omin
gs a
nd g
oing
s
Info
rm th
e pa
tient
who
will
be
thei
r nam
ed n
urse
and
that
the
nam
ed n
urse
will
be
intr
oduc
ed to
th
em w
hen
they
are
nex
t on
duty
Com
plet
e M
enta
l Hea
lth fo
rms
and
obta
in A
SW re
port
. Pro
vide
pat
ient
with
info
rmat
ion
rega
rdin
g M
enta
l Hea
lth O
rder
All
com
mun
ity a
sses
smen
t pap
erw
ork
is a
vaila
ble
to th
e ad
mitt
ing
team
whe
n th
e pa
tient
arr
ives
on
the
war
d,
incl
udin
g m
enta
l hea
lth a
nd c
urre
nt ri
sk a
sses
smen
t
Rein
forc
e th
e ho
pe a
nd o
ptim
istic
app
roac
h to
reco
very
. Cla
rify
expe
ctat
ions
sta
ff ha
ve o
f the
pat
ient
in te
rms
of
the
patie
nt’s
str
uctu
red
day,
resp
ect o
f pro
pert
y, p
erso
nal d
igni
ty to
oth
ers,
nee
d fo
r obs
erva
tion
and
regu
latio
ns
conc
erni
ng s
mok
ing,
alc
ohol
& d
rugs
The
patie
nt a
nd a
ccom
pany
ing
pers
on a
re m
et o
n ar
rival
, sho
wn
to a
n ap
prop
riate
are
a an
d of
fere
d re
fres
hmen
ts
The
patie
nt is
intr
oduc
ed to
a m
embe
r of s
taff
who
will
be
thei
r poi
nt o
f con
tact
for t
he fi
rst f
ew h
ours
Con
side
r nee
d fo
r an
inte
rpre
ter
Che
ck th
e pa
tient
pro
pert
y to
ens
ure
no ri
sk/b
anne
d ite
ms,
reco
rdin
g an
y pr
oper
ty re
tain
ed b
y st
aff o
n re
leva
nt fo
rm
Iden
tify
any
com
mun
icat
ion
issu
es s
uch
as p
refe
rred
lang
uage
/vis
ual o
r hea
ring
impa
irmen
t
Com
plet
e ad
mis
sion
che
cklis
t
Com
plet
e co
re a
dmin
doc
umen
tatio
n/da
ta c
olle
ctio
n (o
n ch
eckl
ist)
Patie
nt re
ceiv
es s
tand
ard
med
ical
and
nur
sing
ass
essm
ents
and
phy
sica
l exa
min
atio
n
Ass
essm
ent o
f cap
acity
to c
onse
nt
Com
plet
e Re
cove
ry P
lan
in C
onsu
ltatio
n w
ith p
atie
nt 7
2 ho
urs
Is th
e pa
tient
det
aine
d un
der t
he M
enta
l Hea
lth O
rder
?
Nex
t go
to
Stag
e 4
Ass
essm
ents
Arr
ival
Cla
rify
the
ratio
nale
for
adm
issi
on
Prio
rity
area
s fo
r im
med
iate
in
terv
entio
n:sa
fety
, phy
sica
l he
alth
,se
lf-ca
re a
nd
soci
al n
eeds
Asc
erta
in fr
om th
e re
ferr
ing
agen
cy in
form
atio
n as
to th
e se
curit
y of
the
patie
nt’s
hom
e, w
here
abou
ts o
f chi
ldre
n or
pet
s
23
Stage 4Admission
Within first 24 hours
Begi
n di
scha
rge
plan
ning
Patie
nt is
giv
en th
e w
ard
info
rmat
ion
book
let w
ith in
form
atio
n on
adv
ocac
y ex
plai
ning
any
ne
cess
ary
poin
ts to
pro
mot
e un
ders
tand
ing
Nex
t - g
o to
sta
ge 5
- A
sses
smen
t - F
irst 7
2 ho
urs
Esta
blis
h w
ho a
re th
e re
lativ
es a
nd c
arer
s an
d if
the
patie
nt c
onse
nts
to th
em b
eing
giv
en
info
rmat
ion
or b
eing
invo
lved
in c
urre
nt c
are.
Info
rm re
; Adv
ocac
y fo
r car
ers
Info
rm C
MH
T or
oth
er s
ervi
ces
curr
ently
invo
lved
with
ser
vice
use
r, re
ques
ting
any
appr
opria
te
info
rmat
ion/
adva
nce
dire
ctiv
esC
arry
forw
ard
(with
in 1
day
)
The
war
d pr
omot
esa
ther
apeu
tic a
nd
safe
exp
erie
nce
Serv
ice
user
s an
d ca
rers
are
pro
vide
dw
ith in
form
atio
n ab
out t
he w
ard,
thei
rca
re a
nd tr
eatm
ent
and
are
activ
ely
invo
lved
in p
lann
ing
indi
vidu
al c
are
24
Stage 5Comprehensive Assessment
The first 72 hours
With
in 7
2 H
ours
Go
to S
tage
6
AIM
To p
rovi
de a
co
mpr
ehen
sive
asse
ssm
ent t
o in
form
the
MD
T Re
view
Car
e Pl
an
The
patie
nt m
eets
with
mem
bers
of t
he M
ulti-
Dis
cipl
inar
y Te
am to
com
plet
e th
e w
ard
asse
ssm
ent
with
in th
e fir
st 7
2 ho
urs
of a
dmis
sion
taki
ng in
to c
onsi
dera
tion
disc
ussi
on/
deci
sion
s fr
om d
aily
w
ard
revi
ew. A
ll as
sess
men
ts a
re s
igne
d an
d da
ted.
The
nam
ed n
urse
to c
onta
ct k
ey w
orke
r/an
y re
leva
nt s
ervi
ces
invo
lved
. Ide
ntify
requ
irem
ents
for
early
dis
char
ge p
acka
ge a
nd m
aint
ain
at le
ast w
eekl
y co
ntac
t to
prom
ote
co-o
rdin
atio
n an
d co
mm
unic
atio
n ac
ross
the
syst
em o
f car
e.
Con
duct
a m
ulti-
disc
iplin
ary
form
ulat
ion,
upd
ate
the
Indi
vidu
alis
ed R
ecov
ery
Plan
and
est
imat
e da
te o
f dis
char
ge
Find
ings
from
risk
ass
essm
ents
are
com
mun
icat
ed a
cros
s re
leva
nt a
genc
ies
and
care
set
tings
as
appr
opria
te in
acc
orda
nce
with
the
Trus
t’s In
form
atio
n G
over
nanc
e Po
licy
The
patie
nt is
abl
e to
invo
lve
the
peop
le th
ey re
ly o
n fo
r sup
port
(car
ers/
rela
tives
/nei
ghbo
urs/
-fr
iend
s/ad
voca
te) i
n th
eir a
sses
smen
ts.
25
Stage 6Comprehensive Assessment
Within first week
With
in 1
wee
k
Go
to S
tage
7
AIM
To p
rovi
de a
co
mpr
ehen
sive
asse
ssm
ent t
o in
form
the
MD
T Re
view
Car
e Pl
an
A c
ompr
ehen
sive
hol
istic
ass
essm
ent o
f str
engt
hs, a
reas
of c
once
rn a
nd n
eeds
are
con
side
red
incl
udin
g th
e fo
llow
ing:
- as
sess
men
t of r
isk
- vu
lner
abili
ty-
child
pro
tect
ion/
child
care
- m
enta
l hea
lth s
tate
-
beh
avio
ur
- c
ogni
tive
-
hal
luci
natio
ns/d
elus
ions
-
moo
d-
patte
rns
of s
ubst
ance
mis
use
incl
udin
g al
coho
l-
phys
ical
hea
lth c
are
mon
itorin
g
The
prin
cipl
e ca
rer i
s of
fere
d an
inte
rvie
w w
ithin
3 w
orki
ng d
ays
of a
dmis
sion
with
a n
amed
pr
ofes
sion
al d
urin
g w
hich
:
- t
he c
arer
’s v
iew
s ab
out o
n-go
ing
and
futu
re in
volv
emen
t are
reco
rded
- t
he c
arer
is g
iven
an
expl
anat
ion
and
an in
form
atio
n sh
eet a
bout
war
d pr
oced
ures
- t
he c
arer
is o
ffere
d in
form
atio
n on
car
er a
dvoc
acy,
wel
fare
righ
ts a
nd m
enta
l hea
lth s
ervi
ces
- t
he c
arer
is o
ffere
d an
ass
essm
ent o
f the
ir ow
n ne
eds
(refe
r via
Soc
ial C
are
Dire
ct/C
MH
T)
• U
se o
f reg
iona
lly a
gree
d cl
inic
al o
utco
me/
mea
sure
men
t too
l•
Use
of R
ecov
ery
Out
com
e To
ol
Ass
essm
ents
to b
e pr
esen
ted
with
in th
e fir
st w
eek
at th
e M
DT
Car
e Re
view
Mee
ting
to d
iscu
ss th
e se
rvic
e us
er’s
car
e, w
ith in
put f
rom
the
CM
HT.
Dis
cuss
dis
char
ge p
lann
ing.
- ph
ysic
al w
ellb
eing
incl
udin
g:
- d
iet/
heal
thy
eatin
g
- p
hysi
cal a
ctiv
ity/e
xerc
ise
- re
latio
nshi
ps/s
ocia
l con
tact
s-
sexu
al o
rient
atio
n/ge
nder
issu
es-
educ
atio
nal n
eeds
(lite
racy
and
num
erac
y)-
acco
mm
odat
ion
- em
ploy
men
t/oc
cupa
tion
- sm
okin
g ce
ssat
ion
- la
ngua
ge/c
ultu
ral i
ssue
s-
spiri
tual
nee
ds
26
Stage 7The Recovery Process
- Weekly cycle
Dai
ly
Twic
e W
eekl
y
Wee
kly
Trea
tmen
tW
eekl
y C
ycle
Repe
at S
tage
7
or g
o to
Sta
ge 8
To p
rom
ote
reco
very
from
men
tal h
ealth
prob
lem
s re
quiri
ngin
-pat
ient
car
e
To p
rom
ote
an
effe
ctiv
e in
tegr
ated
care
pat
hway
to
man
age
care
whi
lst
in h
ospi
tala
nd e
nsur
ea
smoo
th tr
ansi
tion
out o
f hos
pita
l
Revi
ew o
utco
me
- To
reco
rd th
e fo
llow
ing
(if a
pplic
able
):-
brie
f sum
mar
y in
clud
ing
cons
ent,
MH
O is
sues
/sta
tus,
cha
nge
in h
ealth
and
func
tioni
ng
an
d ris
k is
sues
- if
to re
peat
any
ass
essm
ents
/ris
k pr
ofile
s-
iden
tify
on-g
oing
nee
ds a
nd w
ho w
ill m
ake
any
nece
ssar
y re
ferr
als
spec
ifyin
g a
time
pe
riod
for t
he re
ferr
al a
nd re
cord
ing
whe
n se
nt e
g du
al d
iagn
osis
, dru
g an
d al
coho
l etc
.-
iden
tifie
d ne
eds/
agre
ed in
terv
entio
ns (i
nclu
ding
any
cha
nges
)-
est
imat
ed d
ate
of d
isch
arge
-
7 D
ay fo
llow
up
polic
y-
dat
e of
nex
t for
mal
revi
ew
Serv
ice
user
to
be in
volv
ed in
dev
elop
ing
thei
r ca
re p
lan
- v
iew
s re
cord
ed in
the
note
s-
dec
idin
g w
hat i
s in
the
care
pla
n, w
hen/
whe
re/w
ith w
hom
to s
hare
info
rmat
ion
- c
opy
to b
e gi
ven
to th
e pa
tient
and
car
er, i
f pat
ient
agr
ees
- w
ell-b
eing
/car
e pl
an re
view
ed w
eekl
y,
The
patie
nt h
as a
str
uctu
red
day
of m
eani
ngfu
l act
ivity
and
sup
port
ive/
goal
orie
nted
se
ssio
ns w
ith s
taff
Ther
e is
a d
aily
(Mon
- F
ri) w
ard
revi
ew b
etw
een
the
nurs
ing
staf
f, do
ctor
s an
d ot
her r
elev
ant
mem
bers
of t
he M
DT.
Thi
s in
clud
es a
dis
cuss
ion
of e
ach
patie
nt, t
heir
risk
fact
ors,
pat
ient
nee
ds
incl
udin
g th
erap
eutic
act
iviti
es a
nd d
isch
arge
pla
n
A m
ulti-
disc
iplin
ary
revi
ew a
t lea
st w
eekl
y w
ith th
e pa
tient
/car
er/a
dvoc
ate
allo
win
g th
em to
air
thei
r vi
ews
in re
latio
n to
the
care
pac
kage
and
ong
oing
man
agem
ent o
f ris
k. C
MH
T st
aff t
o at
tend
Nam
ed n
urse
at l
east
wee
kly
to li
aise
with
rele
vant
loca
lity
com
mun
ity te
am o
r CRH
T as
ap
prop
riate
to d
iscu
ss p
rogr
ess,
on-
goin
g m
anag
emen
t of r
isk,
dis
char
ge p
lann
ing
and
estim
ated
dis
char
ge/t
rans
fer d
ate
Ther
e is
a n
ursi
ng h
ando
ver a
t eac
h sh
ift w
hich
incl
udes
a d
iscu
ssio
n of
risk
fact
ors
and
patie
nt
need
s -
task
s ar
e id
entif
ied
and
allo
cate
d to
indi
vidu
als
Patie
nts
have
a m
inim
um tw
ice-
wee
kly
docu
men
ted
sess
ion
with
thei
r nam
ed o
r allo
cate
d nu
rse
to re
view
thei
r pro
gres
s an
d ca
re p
lan
Befo
re th
e w
eekl
y re
view
, the
nam
ed n
urse
sho
uld
com
plet
e a
nurs
ing
revi
ew a
t the
sam
e tim
e. It
is
also
goo
d pr
actic
e fo
r the
nam
ed n
urse
and
CM
HT
keyw
orke
r to
liais
e w
eekl
y to
dis
cuss
pro
gres
s
Patie
nts
have
the
oppo
rtun
ity to
mee
t the
ir co
nsul
tant
on
a w
eekl
y ba
sis
The
patie
nt’s
invo
lvem
ent i
s so
ught
in a
ll de
cisi
ons
abou
t the
ir ca
re a
nd tr
eatm
ent
27
Stage 8Discharge
Dis
char
ge in
line
with
med
ical
adv
ice
Follo
w p
roce
ss o
n th
e C
TMA
form
If C
TMA
, car
ry o
ut ri
sk a
sses
smen
t, in
form
GP
and
key
wor
ker.
Con
side
r ass
essm
ent u
nder
MH
O.
Plan
to in
clud
e:-
res
ourc
es re
quire
d fo
r dis
char
ge-
inv
olve
men
t of c
arer
s/ad
voca
tes,
fam
ily a
s ap
prop
riate
- c
onta
ct a
fter d
isch
arge
- u
pdat
e of
risk
ass
essm
ent
Prio
r to
disc
harg
e co
mpl
ete
disc
harg
e ch
eckl
ist:
- s
afet
y pl
ans
and
emer
genc
y co
ntac
t det
ails
- c
ompl
ete
GP
disc
harg
e su
mm
ary,
sen
d to
GP,
pat
ient
, car
ers,
CM
HT
keyw
orke
r-
com
plet
e ou
tcom
es m
easu
re s
urve
y-
dis
trib
ute
user
and
car
e ex
perie
nce
surv
ey
- r
ecov
ery
care
pla
n-
inv
olve
men
t of P
harm
acy
- s
et n
ext E
CP
revi
ew d
ate
Dis
char
ge p
lann
ing
is in
itiat
ed a
s pa
rt o
f for
mul
atio
n an
d re
cove
ry p
lan:
- i
nvol
vem
ent o
f pat
ient
, fa
mily
/car
er in
dis
char
ge p
lan
and
prov
isio
nal d
isch
arge
dat
e -
ide
ntifi
catio
n of
CM
HT
keyw
orke
r and
rele
vant
com
mun
ity re
sour
ces
to m
eet n
eeds
- r
evie
w o
f dis
char
ge d
ate
and
need
s th
roug
h da
ily a
nd w
eekl
y re
view
s
Scre
enin
g fo
r pos
sibl
e ea
rly d
isch
arge
via
dai
ly re
view
pro
cess
Con
side
r as
per P
QC
Enh
ance
d C
are
Plan
(EC
P)
Arr
ange
7 d
ay fo
llow
up
Refe
r to
Hom
e Tr
eatm
ent f
or e
arly
dis
char
ge, w
here
app
ropr
iate
Is e
arly
dis
char
ge p
ossi
ble?
Requ
est f
or e
arly
dis
char
ge?
With
in 2
4 ho
urs
of d
isch
arge
Dis
char
ge is
appr
opria
tely
timed
acc
ordi
ng
to th
e se
rvic
eus
ers
heal
thne
eds
Stag
e 8
Dis
char
ge
appr
opria
tely
tim
ed to
mee
t ne
ed
28
Stage 2HOME TREATMENT
Admission (within the first 24hrs)
Car
ry fo
rwar
d(w
ithin
1 d
ay)
Cla
rify
the
ratio
nale
fo
r ad
mis
sion
.A
reas
for
imm
edia
te
inte
rven
tion:
safe
ty, p
hysi
cal
heal
th, s
elf-
care
and
so
cial
nee
ds
Patie
nts
& C
arer
s ar
e pr
ovid
ed w
ith
info
rmat
ion
abou
t th
eir
care
and
tr
eatm
ent a
nd a
re
activ
ely
invo
lved
in
plan
ning
indi
vidu
al
care
Go
to s
tage
3
Patie
nt a
ccep
ted
for
adm
issi
on to
Hom
e Tr
eatm
ent:
0-4
hour
s
Expl
ain
role
and
func
tion
of th
e te
am in
clud
ing
hour
s of
ope
ratio
n
Rein
forc
e th
e ho
pe a
nd o
ptim
istic
app
roac
h to
reco
very
.D
evel
op a
n in
itial
man
agem
ent a
nd s
afet
y pl
an
Esta
blis
h w
ho a
re th
e re
lativ
es a
nd c
arer
s, a
nd w
ith c
onse
nt s
hare
rele
vant
in
form
atio
n ab
out c
urre
nt tr
eatm
ent p
lan
Giv
e di
rect
acc
ess
cont
act n
umbe
rs to
the
team
24/
7 to
the
patie
nt a
nd c
arer
Info
rmat
ion
Giv
ing/
Shar
ing
Patie
nt g
iven
HTT
info
rmat
ion
book
let/
pack
with
info
rmat
ion
on a
dvoc
acy.
Ex
plai
n al
l poi
nts
to p
rom
ote
unde
rsta
ndin
g
Cla
rify
expe
ctat
ions
sta
ff ha
ve o
f the
pat
ient
in te
rms
of th
e pa
tient
’s
enga
gem
ent w
ith th
e se
rvic
e
Info
rm th
e pa
tient
who
thei
r nam
ed w
orke
r will
be
and
if th
at n
amed
wor
ker i
s no
t co
mpl
etin
g as
sess
men
t tha
t the
y w
ill b
e in
trod
uced
to th
em w
hen
they
are
nex
t on
duty
Adv
ise
the
patie
nt/r
elat
ive
of th
e M
ulti-
Dis
cipl
inar
y Te
am th
at w
ill b
e pr
ovid
ing
trea
tmen
t an
d th
at h
e/sh
e w
ill b
e re
view
ed b
y th
e C
onsu
ltant
Psy
chia
tris
t with
the
first
72
hrs
Info
rm re
ferr
al a
gent
& G
P of
ass
essm
ent o
utco
me
and
adm
issi
on in
to H
ome
Trea
tmen
t
Info
rm C
MH
T or
oth
er s
ervi
ces
curr
ently
invo
lved
with
ser
vice
use
r, re
ques
ting
any
appr
opria
te in
form
atio
n/ a
dvan
ce d
irect
ives
Reco
ncile
med
icat
ions
with
NIE
CR,
GP
and
patie
nt
10. Adult Mental Health Acute Care Pathway Stages - Home Treatment
29
Stage 3Comprehensive Assessment
- The first 72 hours
With
in 7
2 H
rs
Go
to S
tage
4
AIM
To p
rovi
de a
co
mpr
ehen
sive
asse
ssm
ent t
o in
form
th
e M
DT
Revi
ew C
are
Plan
The
patie
nt m
eets
with
Con
sulta
nt P
sych
iatr
ist a
nd K
eyw
orke
r fro
m th
eir M
ulti-
Dis
cipl
inar
y Te
am to
up
date
men
tal s
tate
ass
essm
ent a
nd c
ompl
ete
adm
issi
on a
sses
smen
ts w
ithin
the
first
72
hrs
The
patie
nt is
abl
e to
invo
lve
the
peop
le th
ey re
ly o
n fo
r sup
port
(car
ers/
rela
tives
/nei
ghbo
urs/
-fr
iend
s/ad
voca
te) i
n th
eir a
sses
smen
ts
Con
duct
a m
ulti-
disc
iplin
ary
form
ulat
ion
and
upda
te th
e in
divi
dual
ised
Rec
over
y Pl
an
Find
ings
from
risk
ass
essm
ents
are
com
mun
icat
ed a
cros
s re
leva
nt a
genc
ies
and
care
set
tings
as
appr
opria
te in
acc
orda
nce
with
the
Trus
t’s In
form
atio
n G
over
nanc
e Po
licy
The
nam
ed w
orke
r to
cont
act a
ny k
ey w
orke
r/re
leva
nt s
ervi
ces
invo
lved
. Ide
ntify
requ
irem
ents
for
disc
harg
e an
d m
aint
ain
at le
ast w
eekl
y co
ntac
t to
prom
ote
co-o
rdin
atio
n an
d co
mm
unic
atio
n ac
ross
the
syst
em o
f car
e
30
Stage 4Comprehensive Assessment
- Within the first week
With
in 1
wee
k
Go
to S
tage
5
AIM
To p
rovi
de a
co
mpr
ehen
sive
asse
ssm
ent t
o in
form
the
MD
T Re
view
Car
e Pl
an
A c
ompr
ehen
sive
hol
istic
ass
essm
ent o
f str
engt
hs, a
reas
of c
once
rn a
nd n
eeds
are
con
side
red
incl
udin
g th
e fo
llow
ing:
- as
sess
men
t of r
isk
- vu
lner
abili
ty-
child
pro
tect
ion/
child
care
- m
enta
l hea
lth s
tate
-
beh
avio
ur
- c
ogni
tive
-
hal
luci
natio
ns/d
elus
ions
-
moo
d-
patte
rns
of s
ubst
ance
mis
use
incl
udin
g al
coho
l-
phys
ical
hea
lth c
are
mon
itorin
g
The
prin
cipl
e ca
rer i
s of
fere
d an
inte
rvie
w w
ithin
3 w
orki
ng d
ays
of a
dmis
sion
with
a n
amed
pr
ofes
sion
al d
urin
g w
hich
:
- t
he c
arer
’s v
iew
s ab
out o
n-go
ing,
col
late
ral h
isto
ry g
aine
d re
gula
rly a
nd fu
ture
i
nvol
vem
ent a
re re
cord
ed-
the
car
er is
giv
en a
n ex
plan
atio
n an
d an
info
rmat
ion
shee
t abo
ut th
e te
am-
the
car
er is
offe
red
info
rmat
ion
on c
arer
adv
ocac
y, w
elfa
re ri
ghts
and
men
tal h
ealth
ser
vice
s
Use
of o
utco
mes
mea
sure
s
Ass
essm
ents
to b
e pr
esen
ted
with
in th
e fir
st w
eek
at th
e M
ulti-
Dis
cipl
inar
y Te
am C
are
Revi
ew
mee
ting
to d
iscu
ss th
e pa
tient
’s c
are,
with
inpu
t fro
m th
e C
MH
T. D
iscu
ss d
isch
arge
pla
nnin
g
- ph
ysic
al w
ellb
eing
incl
udin
g:
- d
iet/
heal
thy
eatin
g
- p
hysi
cal a
ctiv
ity/e
xerc
ise
- re
latio
nshi
ps/s
ocia
l con
tact
s-
sexu
al o
rient
atio
n/ge
nder
issu
es-
educ
atio
nal n
eeds
(lite
racy
and
num
erac
y)-
acco
mm
odat
ion
- em
ploy
men
t/oc
cupa
tion
- sm
okin
g ce
ssat
ion
- la
ngua
ge/c
ultu
ral i
ssue
s-
spiri
tual
nee
ds
31
Stage 5The Recovery Process
- Weekly cycle
Dai
ly
Twic
e W
eekl
y
Trea
tmen
tW
eekl
y C
ycle
Repe
at S
tage
5
AIM
To p
rom
ote
reco
very
fr
om m
enta
l hea
lth
prob
lem
s re
quiri
ng
Hom
e Tr
eatm
ent c
are
To p
rom
ote
an
effe
ctiv
e in
tegr
ated
ca
re p
athw
ay to
m
anag
e ca
re w
hils
t in
Hom
e Tr
eatm
ent
and
ensu
re s
moo
th
tran
sitio
n be
twee
n st
ep u
p an
d st
ep
dow
n in
men
tal
heal
th s
ervi
ces
Revi
ew o
utco
me
- To
reco
rd th
e fo
llow
ing
(if a
pplic
able
):-
brie
f sum
mar
y in
clud
ing
cons
ent,
MH
O is
sues
, cha
nge
in h
ealth
and
func
tioni
ng a
nd ri
sk is
sues
- i
f to
repe
at a
ny a
sses
smen
ts/r
isk
prof
iles
- i
dent
ify o
n-go
ing
need
s an
d w
ho w
ill m
ake
any
nece
ssar
y re
ferr
als
spec
ifyin
g a
time
perio
d
for t
he re
ferr
al a
nd re
cord
ing
whe
n se
nt e
g du
al d
iagn
osis
, dru
g an
d al
coho
l etc
.-
ide
ntifi
ed n
eeds
/ag
reed
inte
rven
tions
(inc
ludi
ng a
ny c
hang
es)
- e
stim
ated
dat
e of
dis
char
ge
- 7
Day
follo
w u
p p
olic
y
Serv
ice
user
to
be in
volv
ed in
dev
elop
ing
thei
r ca
re p
lan
- v
iew
s re
cord
ed in
the
note
s-
dec
idin
g w
hat i
s in
the
care
pla
n, w
hen/
whe
re/w
ith w
hom
to s
hare
info
rmat
ion
- c
opy
to b
e gi
ven
to th
e pa
tient
and
car
er if
pat
ient
agr
ees
- R
ecov
ery/
Wel
l-bei
ng c
are
plan
revi
ewed
wee
kly,
The
patie
nt is
enc
oura
ged
to h
ave
a st
ruct
ured
day
and
kee
p lin
ked
in w
ith th
eir c
omm
unity
/usu
al
rout
ine
as w
ell a
s ha
ving
sup
port
ive/
goal
orie
nted
one
-to-
one
sess
ions
with
sta
ff
Ther
e is
a d
aily
(Mon
- F
ri) re
view
bet
wee
n th
e H
ome
Trea
tmen
t sta
ff, d
octo
rs a
nd o
ther
rele
vant
m
embe
rs o
f the
MD
T. T
his
incl
udes
a d
iscu
ssio
n of
eac
h pa
tient
, the
ir ris
k fa
ctor
s, p
atie
nt n
eeds
in
clud
ing
ther
apeu
tic a
ctiv
ities
and
dis
char
ge p
lan
Nam
ed w
orke
r at l
east
wee
kly
to li
aise
with
rele
vant
loca
lity
com
mun
ity te
am a
s ap
prop
riate
to
disc
uss
prog
ress
, on-
goin
g m
anag
emen
t of r
isk,
dis
char
ge p
lann
ing
and
estim
ated
di
scha
rge/
tran
sfer
dat
e
Ther
e is
a s
taff
hand
over
at e
ach
shift
whi
ch in
clud
es a
dis
cuss
ion
of ri
sk fa
ctor
s an
d pa
tient
nee
ds
- ta
sks
are
iden
tifie
d an
d al
loca
ted
to in
divi
dual
s
Patie
nts
have
a m
inim
um tw
ice-
wee
kly
docu
men
ted
sess
ion
with
thei
r nam
ed o
r al
loca
ted
wor
ker t
o re
view
thei
r pro
gres
s
Patie
nt re
quire
s fu
rthe
r tre
atm
ent
Patie
nt re
ady
for
disc
harg
ePa
tient
’s tr
eatm
ent c
an n
o lo
nger
be
safe
ly m
anag
ed
in th
e co
mm
unity
A m
ulti-
disc
iplin
ary
revi
ew a
t lea
st w
eekl
y by
the
team
, the
nam
ed w
orke
r to
disc
uss
with
pa
tient
/car
er/a
dvoc
ate
allo
win
g th
em to
air
thei
r vie
ws
in re
latio
n to
the
care
pac
kage
and
ong
oing
m
anag
emen
t of r
isk.
Patie
nts
have
the
oppo
rtun
ity to
be
revi
ewed
by
thei
r con
sulta
nt o
n a
wee
kly
basi
s if
nece
ssar
y
The
patie
nt’s
invo
lvem
ent i
s so
ught
in a
ll de
cisi
ons
abou
t the
ir ca
re a
nd tr
eatm
ent
Go
to S
tage
6G
o to
Sta
ge 2
of
In-p
atie
nt P
athw
ay
32
Stag
e 6
Dis
char
ge
appr
opria
tely
tim
ed to
mee
t ne
ed
Dis
char
ge is
ap
prop
riate
ly
timed
ac
cord
ing
to
the
patie
nt’s
he
alth
nee
ds
Dis
char
ge p
lann
ing
is in
itiat
ed a
s pa
rt o
f for
mul
atio
n an
d re
cove
ry p
lan:
• in
volv
emen
t of p
atie
nt a
nd s
igni
fican
t oth
ers
in d
isch
arge
pl
an a
nd p
rovi
sion
al d
isch
arge
dat
e •
iden
tific
atio
n of
CM
HT
keyw
orke
r and
rele
vant
com
mun
ity
reso
urce
s to
mee
t nee
ds•
revi
ew o
f dis
char
ge d
ate
and
need
s th
roug
h da
ily a
nd
wee
kly
revi
ews
With
in 2
4Hrs
of d
isch
arge
Prio
r to
dis
char
ge c
ompl
ete
disc
harg
e ch
eckl
ist:
• C
ompl
ete
disc
harg
e/tr
ansf
er c
are
plan
– in
clud
ing
safe
ty
plan
s an
d em
erge
ncy
cont
act d
etai
ls•
Com
plet
e G
P di
scha
rge
sum
mar
y, s
end
to G
P, p
atie
nt,
care
rs, C
MH
T ke
ywor
ker
• C
ompl
ete
outc
omes
mea
sure
sur
vey
• D
istr
ibut
e us
er a
nd c
are
expe
rienc
e su
rvey
Is D
isch
arge
app
ropr
iate
?
Dis
char
ge in
line
with
med
ical
adv
ice
and
Hom
e Tr
eatm
ent
Proc
edur
es
Arr
ange
Fol
low
up
App
oint
men
ts
If Pa
tient
dis
enga
ges
with
the
team
Con
tact
Car
er/r
elat
ive
cons
ider
ass
essm
ent u
nder
MH
O
Plan
to in
clud
e:•
reso
urce
s re
quire
d fo
r dis
char
ge•
invo
lvem
ent o
f car
ers/
advo
cate
s, fa
mily
as
appr
opria
te•
con
tact
afte
r dis
char
ge•
upd
ate
of ri
sk a
sses
smen
t•
reco
very
car
e pl
an•
invo
lvem
ent o
f Pha
rmac
y•
set
nex
t EC
P re
view
dat
e
Stage 6Discharge
33
34
11. Supporting Resources
i. Health and Social Care Board, (2014) You In Mind Regional Mental Health Care Pathway
ii. Department of Health (2001) Crisis Resolution/Home Treatment Teams: The Mental Health Policy Implementation Guide. Department of Health http://apt.rcpsych.org/content/19/2/115#ref-17
iii. The Joint Commissioning Panel for Mental Health Guidance for commissioners of acute care – inpatient and crisis home treatment www.jcpmh.info
iv. iv) NICE (2011) Clinical guidance 136 - Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services https://www.nice.org.uk/guidance/cg136
v. DOH (2002) Mental Health Policy Implementation Guide - National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments www.napicu.org.uk/wp-content/uploads/2013/04/ 2002-NMS.pdf
vi. Leicestershire Partnership NHS Trust, Adult Mental Health Acute Care Pathway, October 2012
vii. http://www.jcpmh.info/commissioning-tools/cases-for-change/crisis/what-works/crisis-houses
viii. http://www.jcpmh.info/
Standards are provided in DOH Mental Health Policy Implementation Guide National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments HSCB, (2015), You in Mind Talking Yourself Well – A Guide to Mental Health Psychological Therapies.
Supporting Resources
35Acute Mental Health Care Pathway - Northern Ireland
12. Glossary
Acute psychiatric care - Acute psychiatric care is the treatment and support provided to people who are either experiencing, at risk of, or recovering from a mental health crisis. This could include in-patient care on acute psychiatric wards, care in the community by a CRHT, care in acute day services or in crisis/recovery houses.
Acute psychiatric wards - Acute psychiatric wards provide in-patient care to people when their illness cannot be managed in the community.
Bamford Review of Mental Health and Learning Disability The Bamford Review was commissioned in 2002 by the DHSSPS and reviewed the law, policies and provision of services relevant to both mental illness and learning disability. It concluded its work in 2007 but, alongside Transforming Your Care, has remained the main framework for continuing improvements in mental health and learning disability services in Northern Ireland.
Community Mental Health Teams (CMHT) and Primary Care and Recovery Teams (PCRT) - CMHTs and PCRTs are secondary mental health services which provide support to people living in the community who have complex or serious mental health problems.
Crisis House - Crisis houses are community-based crisis services that offer residential support to people experiencing a mental health crisis. There are various models of crisis house and they can be clinical or non-clinical in nature.
Crisis Resolution and Home Treatment Team (CRHT) - CRHTs provide intensive support in the community to people experiencing a mental health crisis as an alternative to inpatient care.
Extra Contractual Referrals (ECRs) - ECRs occur when patients from Northern Ireland are transferred abroad for care as they require treatment or services not available in the region.
Mental Health (Northern Ireland) Order 1986 - The Mental Health (Northern Ireland) Order 1986 is the legislation governing the care, treatment and protection of persons with a mental disorder in Northern Ireland. Significant changes to the legislation were proposed by the Bamford Review and draft legislation – The Mental Capacity Bill – has been published to this effect.
Rehabilitation Psychiatry Services Rehabilitation Psychiatry services aim to promote recovery for people with severe and complex mental health problems by minimising symptoms and promoting social inclusion, in order to support patients to live as independently as possible.
Releasing Time to Care/Productive Ward - The Releasing Time to Care/The Productive Ward approach was introduced in Northern Ireland in September 2009 in a joint Public Health Agency (PHA)/Health and Social Care Board (HSCB) initiative. It aims to improve ward processes and environments to help nurses and therapists spend more time on patient care.
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13. Bibliography
David Flory (2008) In Department of Health (2008) Laying the Foundation for Better Acute Mental Healthcare. www.dh.gov.uk
Department of Health (2008) Laying the Foundation for Better Acute Mental Healthcare.
Janner, M (2006) Star Wards: Practical Ideas for Improving the Daily Experiences and Treatment Outcomes of Acute Mental Health Inpatients. http://starwards.org.uk
MIND (2006) Building Solutions – Improving Mental Health Environments
National Mental Health Development Unit Triangle of Care
National Patient Safety Agency (2006) With Safety In Mind: Mental Health Services and Patient Safety
NHS Institute for Innovation and Improvement (2009) The Productive Ward.
Royal College of Psychiatrists (2010) Acute Inpatient Services Accreditation. 4th Edition January 2010 Pub. No. CRTU040
Royal College of Psychiatrists (1998) - Not just Bricks and Mortar.
Royal College of Psychiatrists (2011) Do the Right Thing: How to Judge a Good Ward: Ten Standards for Adult Inpatient Mental Health Care. OP79, June. London: Royal College of Psychiatrists.
The Commission to review the provision of Acute Inpatient Psychiatric Care for Adults (2016) Building on Progress: Achieving Parity for Mental Health in Northern Ireland. June 2016.
College of Occupational Therapists, (2010), Recovering Ordinary Lives: The Strategy for Occupational Therapy in Mental Health Services, 2007-17
NHS England, (2016) A Co-Production Model: Five Values and Seven Steps to Make This Happen in Reality
Bibliography
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14. Appendix 1
Therapeutic Interventions Explained
A range of evidence-based psychological interventions may be offered within acute care. Suitable interventions will tend to be brief, structured, and focused on stabilisation and enhancing coping skills. The choice of intervention should be guided by the patient’s level of functioning and an understanding of their psychological formulation.
Cognitive Behavioural Therapy (CBT) is a collaborative and goal-focused therapy which is recommended for a wide range of difficulties such as anxiety, depression and psychosis. It helps people to understand the links between their thoughts, feelings, and behaviour, and teaches skills for addressing negative thinking and changing unhelpful behaviour patterns.
Behavioural Activation focuses on reducing avoidance and increasing engagement in a range of activities (routine, pleasurable, and necessary), which can impact positively on mood.
Mindfulness-based interventions emphasise increasing awareness of the present moment, adopting a stance of non-judgemental acceptance. Such approaches are useful for reducing emotional avoidance, enhancing emotional awareness and expression, and increasing opportunities for responding skilfully to distressing psychological experiences (by stepping back from such experiences rather than being overwhelmed by them).
Dialectical Behavioural Therapy (DBT) is a therapeutic approach that teaches skills in mindfulness, distress tolerance, interpersonal effectiveness (eg assertiveness skills), and emotion regulation. It helps people to develop new skills for managing overwhelming emotions, building a life worth living, and addressing issues such as self-harm and suicidality.
Other useful interventions within acute care can include relaxation techniques, problem solving, psycho education, motivational interviewing (eg for addressing ambivalence about change in relation to alcohol and substance misuse issues), Wellness Recovery Action Planning (WRAP) (a recovery focused approach that facilitates self-management and identifies personal wellness resources), approaches that can help people make sense of their experience of admission, and support around relapse prevention, as well as Family Interventions and carer support.
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Notes
http://www.hscboard.hscni.net/our-work/social-care-and-children/mental-health/
