developing a community based mental health service in a rural community margaret fleming rpn,...
TRANSCRIPT
Developing a Community Based Mental Health Service in a Rural
Community
Margaret Fleming RPN, FFNRCSI, MSc
International Mental Health Collaborating Network(IMHCN)
SETTING THE CONTEXT Ireland
How Health Services are Delivered in Ireland
Cavan Monaghan Mental Health Service
Change Management/Whole Systems Working
Community Mental Health Teams
Home Base Treatment
Evaluation
The Question ?
Ireland
Health Service Executive Areas
Health Service Executive Ireland
Cavan/Monaghan Mental Health Service
CAVAN/MONAGHAN MENTAL HEALTH SERVICE
POPULATION 119,000
TOTAL SQ. KM.3,300
DEPRIVATION RATE CAVAN 10.7% MONAGHAN 4.7%
BUGET 17 MILLION EURO
PER CAPITA 143 EURO
Change Management WHOLE SYSTEMS APPROACH
PRINCIPLES
• A specialist service
• A service with a single point of access that is easily accessible, available and responsive
• A service which has at it’s core the primacy of service users needs and rights
• A service which delivers an individualised effective treatment package in the setting of home and family
Core Elements of Service Structure
4 Functional Specialist Teams
• Monaghan Community Mental Health Team with Home Base Nursing
• Cavan Community Mental Health Team with Home Base Nursing
• Community Rehabilitation Team with Assertive Outreach Nursing
• Psychiatry of Later Life with Home Base Nursing
CAVAN/MONAGHAN MENTAL HEALTH SERVICE
POPULATION 119,000
TOTAL SQ. KM.3,300
DEPRIVATION RATE CAVAN 10.7% MONAGHAN 4.7%
BUGET 17 MILLION EURO
PER CAPITA 143 EURO
REFERRAL SYSTEM PRE 1998
REFERRING AGENTS
CONSULTANT PSYCHIATRISTS
OCCUPATIONAL THERAPY
BEHAVIOURAL THERAPY
SOCIAL WORKERS
PSYCHOLOGISTS
NURSES / CPN
FAMILY THERAPY
ADDICTION COUNSELLORS
REFERRING AGENTS
Monaghan
CavanCarrickmacross
Bailieborough
COMMUNTIY REHABILITATION TEAM (POP. 119,000)
PSYCHIATRY OF LATER LIFE
ADDICTION SERVICES
Community Mental Health Team
Community Mental Health
Team
TEAM BUILDING
Meetings Operational policies HBTT /gatekeeper of Acute Beds Single point of access Multidisciplinary team Service Directory
BIO PSYCHO SOCIAL MODEL
Mental distress does not occur in a vacuum but in the context of peoples’ lives.
Context gives meaning
Creating Partnerships
With Service-usersWith Carers/Families/Significant othersWith G.P’sReassuranceAction
COMMUNITY MENTAL HEALTH
Mental health is a community issue
A community resource based model has at its foundation Housing Employment Education Income
ELEMENTS OF CITIZENSHIP
Rights to:
Equality of opportunity Economic security. Justice and respect. Freedom of speech. Freedom of choice. To be an individual. Self-determination.
Developing Collaborative Alliances Within the
Community
Meetings
Interagency networking
Collaboration
Coalitions
BIO-PSYCHOSOCIAL MODEL OF CARE
Service-user centred Service-user ownership Importance of involving the family / significant others Recognising social and personal resources Community as a resource to encourage and promote
normal social relationships Empowerment Participation Collaboration / Interagency Interdependence not independence
SERVICE USER
CPN
Acute inpatient
Admin
Addiction
Family Therapy
H.B.T.
Medical Secretaries
S.W.
Psychology
O.T.Behavioural Therapy
Medical Team
Management
Health promotion
Education
Women’s Groups
Voluntary groups
Eemployment
Housing
Advocacy
Solas
GardaíCommunity Care
Primary care
Self Help
Youth Groups
Community
Service user
Family / carers
Mental health professionals
Primary care / social services
Voluntary / statutory organisations
National community
Community Mental Health Teams
Monaghan
CavanCarrickmacross
Bailieborough
COMMUNTIY REHABILITATION TEAM (POP. 119,000)
PSYCHIATRY OF LATER LIFE
ADDICTION SERVICES
Community Mental Health Team
Community Mental Health
Team
MONAGHAN Community Mental Health Team
1 Clinical Co-ordinator 2 Consultant psychiatrist 1 Senior Registrar 3 Registrar 6 Home based treatment team 1 Community support worker 3 Community psychiatric nurses 1 Secretary 1.5 Cognitive Behavioural
Psychotherapists 2 Family therapists
1 Occupational therapist 1 Psychologist 1 Social worker 4 Addiction counsellors Acute unit Day Hospital Service-user Resource Centre Advocacy
REFERRAL PATHWAY
M O N AG H AN C AVAN C O M M U N ITY M EN TAL H EALTH TEAM
H .B .T . / A C U TE IN P A T IE N T
P S Y C H IA T R IC E M E R G E N C Y M U L T ID IS C IP L IN A R Y T E A M
T E A M C O -O R D IN A T O R
P R IM A R Y C A R E
COMMUNITY REHABILITATION TEAM
Clinical
Coordinator
CPN
Acute inpatient
Admin
Addiction
Family Therapy
H.B.T.
Medical Secretaries
Social Worker
Psychology
O.T.Behavioural Therapy
Medical Team
Management
HOMEBASE TREATMENT
HOME BASED TREATMENT TEAM MISSION STATEMENT
The Home Based Treatment Team aims to work intensively in a focused way with service-users and their families
during the acute phase of their illness, incorporating a care programme approach to treatment and supporting clients in
reaching their optimum level of recovery
Purpose ofHome Based Treatment
• Gate Keepers of Acute Beds
• Alternative to Hospitalization
• 2 hour response time
• Crisis focused
• Facilitates Early Discharge from Hospital
RECIPROCAL PROCESS OF EMPOWERMENT
EmpowermentInformation
Choice
Decision Making
ControlResponsibility
Accountability
Self Value
Self Esteem
Confidence
Home Based Treatment is Recovery Orientated
15% 30%
15% 40%
HOME BASED NURSING IS BUILT ON PARTNERSHIPS
Service users Families Significant others Choice Participation Collaboration /
Interagency Interdependence
not independence
Core competencies
Respect for people experiencing mental distress and their families.
Understanding of the most effective approaches and of the societal, community, and system factors affecting recovery.
Knowledge of a variety of treatment and support strategies.
Ability to design and deliver individualized supports with an emphasis on (non mental health) resources and to access and employ those resources.
Holders of hope, self-respect and self-esteem. Belief in recovery. Determination, tenacity, persistence, faith and
love.
Home Base Procedure
Referral to Community Mental Health Team Joint assessment by HBT nurse and medical staff Determine if HBT can be an option Joint plan of care drawn up, incorporating supports i.e.
family/carers Level of support decided jointly with
service-user/family/HBT and medical staff Contractual arrangements with service-user and family/
carers agreed.
Arranges earliest possible home visit
Builds a trustworthy relationship with service-user and family
Meets with family and carers Maintains a proactive role throughout treatment
Carries out assessment i.e. FACE
www.face.eu.com/our-products/assessment-tools/mental-health-assessment-toolset
Service-user and relatives are also given verbal and written educational/self-help information
Liaises closely with medical staff
and team leader. HBT liaises with other disciplines to ensure follow up care after discharge
HBTT meetings twice weekly
HBTT Nurse Then:
There are three levels of support:
•Intensive Able to spend time flexibly with service-user and social network including several visits daily if required
•Less intensivealternative days, twice weekly
•Continual Careonce weekly/fortnightly
HousingEmployment
Benefits Medication management
CRITERIA FOR INTRODUCTION OF HOME-BASED TREATMENT
The service-user has been identified as being acutely mentally ill with a risk of further deterioration
There is a perceived need for admission to hospital The needs of the service-user cannot be met by the key
worker/ team because of increasing complexities Service-user/family/carer is agreeable for Home
Treatment nurse/team to implement a care programmed.
THIS WORK IS ACHIEVED BY PROVIDING A VARIETY OF SERVICES AND SUPPORTS
INCLUDING
Quick response on referral – 2 hours Joint assessment at home or at venue of choice Discussion and planning of a care programme with
service-user and significant others Explanation, advice and support to service-user and
family re nature of illness, treatment and expected outcomes
Intensive support to service-user and family Encouragement of normal activities where possible
Crisis work with the service-user and family including coping strategies
HBT remains involved throughout the crisis until it’s resolution
Constant review of progress by involved disciplines
Gradual withdrawal with recovery and linking up to further continuing care
WHY HOME BASED TREATMENT?“Home based treatment is a safe, effective and feasible alternative to hospital care for up to 80% patients with acute psychiatric disorder and one that they and their
carers generally prefer.” (Smyth & Hoult, 2000)
It provides a proven research based alternative to hospital admission
Avoids the trauma of admission on the service user and their family
Provides choice for service users Upholds civil liberty The clinical benefit is the same or better It decreases the stigma attached to hospital admission Assessment of needs are more social based
Assistance in addressing social issues surrounding the crisis from the beginning
Can provide practical problem solving help Avoids lengthy hospitalization Greater service-user satisfaction often resulting in better
engagement and concordance Greater family/carer satisfaction, education and support Avoids residual symptomatology sometimes associated
with hospital admission
GP DetailsPersonal details Affix label here
key worker's): Consultant;
referral details
treatment to date
ICD 10 Diagnosis
medications on discharge
discharge plan
SERVICE USER
CPN
Acute inpatient
Admin
Addiction
Family Therapy
H.B.T.
Medical Secretaries
S.W.
Psychology
O.T.Behavioural Therapy
Medical Team
Management
Health promotion
Education
Women’s Groups
Voluntary groups
Eemployment
Housing
Advocacy
Solas
GardaíCommunity Care
Primary care
Self Help
Youth Groups
EVALUATION
Overall feeling about the cooperation between service providers
Mostly Dissatisfied
5%
Mostly Satisfied68%
Excellent27%
Mostly Dissatisfied Mostly Satisfied Excellent
Overall view of confidentiality and respect shown for clients rights
0
10
20
30
40
50
60
70
terrible mostly dissatisfied mixed mostly satisfied excellent
perc
ent
GP CARER CLIENT
Overall level of satisfaction with the service.
0
10
20
30
40
50
60
70
GP Carer Client
Mixed Mostly satisfied Excellent
The response of the service to crsis or urgent needs.
0
10
20
30
40
50
60
70
Patient Carer GP
Mixed Mostly Satisfied Excellent
Rates per 100,000 of the Population
Activities of Irish Psychiatric Hospitals 2009
HSE Area All Admissions Involuntary Admissions
HSE Dublin North East
449.1 31.3
HSE South 508.0 43.7
Admission Rates per 100,000 of the Population
Activities of Irish Psychiatric Hospitals 2009
Admission Rates per 100,000 of the Population
Activities of Irish Psychiatric Hospitals 2009
1st Admission Rates per 100,000 of the Population
Activities of Irish Psychiatric Hospitals 2009
Monaghan 44.6
Cavan 81.2
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Copyright - Cavan Monaghan Mental Health Service
Go to the people
Live among them
Start with what they know
Build on what they have
Be of the best leaders
When their task is accomplished
Their work is done
The people all remark
We have done it ourselves
THANK YOU
WHAT FACILITATES RECOVERY ?
15% 30%
15% 40%
T O P D O W N SU PE R V ISOR Y C O NT R O LM IN IM A L N E E D FOR D ISC R E T IO N
R E LIA N C E O N R U LE , JOB SPE C IFICR IG ID , LIT T LE INFLU E N C E
T R A D IT IO NA L ST Y L E
MANAGEMENT STYLE
LEADERSHIP MANAGEMENT STYLE
M O T IV A T IO N , IN N O V A T IO N , C R E A T IV ITYO P E N T O C H A N G E , JO B S A T IS F A C T IO N
R E D U C E D D E M A N D S O N M A N A G E M E N T T IM E
F L E X IB L E , C O M P E T E N TA U T O N O M O U S , D E C IS IO N M A K IN G
S H A R E D P L A N N IN G , R E S P O N S IB IL IT IE SA C C O U N T A B IL IT Y A N D O U T C O M E S
T E A ME Q U A L IT Y , C O L L E C TIV E , C O LL A B O R A T IV E , C O M M U N IC A T IV E
(W o rk in g )
H O R IZ O N T A L
CitizenshipRecoveryRiskLeadershipBeliefEngagement Thinking outside the boxOrganisational CultureManagement horizontal versus BureaucraticOver managedAutocraticMutual RespectCollaborationPartnership