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
ADDICTION COUNSELLORS
FAMILY THERAPY
BEHAVIOURAL THERAPY
SOCIAL WORKERS
NURSES / CPN
PSYCHOLOGISTS
REFERRING AGENTS
COMMUNTIY REHABILITATION TEAM (POP. 119,000)
PSYCHIATRY OF LATER LIFE
ADDICTION SERVICES
Community
Mental Health
Team
Monaghan
Carrickmacross
Cavan
Community Mental
Health Team
Bailieborough
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-users
 With Carers/Families/Significant others
 With G.P’s
 Reassurance
 Action
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
Gardaí
Community
Care
Acute
inpatient
Primary care
S.W.
Self Help
H.B.T.
Admin
CPN
Addiction
Solas
Advocacy
Medical
Secretaries
SERVICE
USER
Youth
Groups
Housing
Family
Therapy
Management
Medical
Team
O.T.
Behavioural
Eemployment
Therapy
Psychology
Voluntary
groups
Women’s Groups
Education
Health promotion
Service
user
Family / carers
Community
Mental health professionals
Primary care / social services
Voluntary / statutory organisations
National community
Community Mental Health Teams
COMMUNTIY REHABILITATION TEAM (POP. 119,000)
PSYCHIATRY OF LATER LIFE
ADDICTION SERVICES
Community
Mental Health
Team
Monaghan
Carrickmacross
Cavan
Community Mental
Health Team
Bailieborough
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
MONAGHAN CAVAN COMMUNITY MENTAL HEALTH TEAM
PRIMARY CARE
TEAM CO-ORDINATOR
PSYCHIATRIC EMERGENCY
MULTIDISCIPLINARY TEAM
H.B.T. / ACUTE INPATIENT
COMMUNITY REHABILITATION TEAM
Acute
inpatient
Social
Worker
H.B.T.
Admin
CPN
Addiction
Medical
Secretaries
Clinical
Coordinator
Family
Therapy
Management
Medical
Team
O.T.
Behavioural
Therapy
Psychology
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 of
Home 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
Empowerment
Confidence
Information
Self Esteem
Choice
Self Value
Decision Making
Accountability
Control
Responsibility
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 serviceuser/family/HBT and medical staff
 Contractual arrangements with service-user and family/
carers agreed.
HBTT Nurse Then:
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
Service-user and relatives are also
given verbal and written
educational/self-help information
www.face.eu.com/ourproducts/assessmenttools/mental-healthassessment-toolset
Liaises closely with medical staff
and team leader.
HBTT meetings twice weekly
HBT liaises with other disciplines
to ensure follow up care after
discharge
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 intensive
alternative days, twice weekly
•Continual Care
once weekly/fortnightly
Housing
Employment
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
Personal details
Affix label here
GP Details
key worker's):
Consultant;
referral details
treatment to date
ICD 10 Diagnosis
medications on discharge
discharge plan
Gardaí
Community
Care
Acute
inpatient
Primary care
S.W.
Self Help
H.B.T.
Admin
CPN
Addiction
Solas
Advocacy
Medical
Secretaries
SERVICE
USER
Youth
Groups
Housing
Family
Therapy
Management
Medical
Team
O.T.
Behavioural
Eemployment
Therapy
Psychology
Voluntary
groups
Women’s Groups
Education
Health promotion
EVALUATION
Overall feeling about the cooperation between
service providers
Excellent
27%
Mostly
Dissatisfied
5%
Mostly Satisfied
68%
Mostly Dissatisfie d
Mostly Satisfie d
Exce lle nt
Overall view of confidentiality and respect shown for clients rights
GP
CARER
CLIENT
70
60
percent
50
40
30
20
10
0
terrible
mostly dissatisfied
mixed
mostly satisfied
excellent
Overall level of satisfaction with the service.
Mixed
Mostly satisfied
Excellent
70
60
50
40
30
20
10
0
GP
Carer
Client
The response of the service to crsis or urgent needs.
Mixed
Mostly Satisfied
Excellent
Carer
GP
70
60
50
40
30
20
10
0
Patient
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
Type:
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
Copyright - Cavan Monaghan Mental Health
Service
THANK YOU
WHAT FACILITATES
RECOVERY ?
15%
30%
15%
40%
MANAGEMENT STYLE
TRADITIONAL STYLE
TOP DOWN SUPERVISORY CONTROL
MINIMAL NEED FOR DISCRETION
RELIANCE ON RULE, JOB SPECIFIC
RIGID, LITTLE INFLUENCE
LEADERSHIP MANAGEMENT STYLE
HORIZONTAL
TEAM
EQUALITY, COLLECTIVE, COLLABORATIVE, COMMUNICATIVE
(Working)
SHARED PLANNING, RESPONSIBILITIES
ACCOUNTABILITY AND OUTCOMES
FLEXIBLE, COMPETENT
AUTONOMOUS, DECISION MAKING
MOTIVATION, INNOVATION, CREATIVITY
OPEN TO CHANGE, JOB SATISFACTION
REDUCED DEMANDS ON MANAGEMENT TIME
Citizenship
Recovery
Risk
Leadership
Belief
Engagement Thinking outside the box
Organisational Culture
Management horizontal versus Bureaucratic
Over managed
Autocratic
Mutual Respect
Collaboration
Partnership