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