CRISIS RESOLUTION HOME TREATMENT
OPERATIONAL POLICY
Final Draft
April 2008
The Chinese languages have been built carefully and with no small measure of wisdom.
There is a Chinese ideogram / character for the word crisis, which has two little word pictures.
When you view them separately, you'll find that they translate into English as, "danger" and "opportunity".
Every crisis has both, unfortunately many of us see only the danger in the crisis and miss a valuable opportunity to change and grow.
CONTENTS
1.INTRODUCTION
2.VALUES UNDERPINNING THE MODEL OF SERVICE DELIVERY
3.WHAT IS THE SERVICE INTENDING TO ACHIEVE?
4. REFERRAL PATHWAYS AND HOURS OF OPERATION
4.1 Crisis assessment
4.2 Home treatment
5. WHO IS THE SERVICE FOR?
5.1 Crisis Assessment
5.2 Home Treatment
6. WHO IS THE SERVICE NOT APPROPRIATE FOR?
6.1 Crisis Assessment
6.2 Home Treatment
7.WHAT DOES THE SERVICE DO?
Assessment & planning
7.1 Crisis Assessment
7.2 Home Treatment
Intervention
7.3 Crisis Assessment
7.4 Home Treatment
Resolution
7.5 Crisis Assessment
7.6 Home Treatment
8.CASELOAD
9.MEDICAL COVER
10.WORKING WITH THE IN - PATIENT SERVICE
11.RESPONSE TO MENTAL HEALTH ACT ASSESSMENTS
12. EVALUATION AND MONITORING
1.INTRODUCTION
This Operational Policy has been produced after extensive consultation with Key Stakeholders, Service Users and their Families / Carers. It also reflects the Welsh Assembly Government’s, ‘Policy Implementation Guidance on the Development of Crisis Resolution Home Treatment Services in Wales’ (2005) and the Sainsbury Centre report for the ‘Remodelling of Mental Health Services in Merthyr Tydfil and CynonValley’.
The aim of this document is to provide an outline of how the Crisis Resolution service is accessed and what it provides. Other service protocols and procedures will be developed to support the Operational Policy and team working.
2.VALUES UNDERPINNING THE MODEL OF SERVICE DELIVERY
- A service that accurately reflects the needs of the locality
- Whole systems approach to managing crisis
- Greater choice as to where support or care is provided
- Existing Care Coordinator role is central to continuity of care
- A whole person perspective towards intervention – not just focusing on the illness model
- Commitment towards Service User and Carer effective partnerships within proactive crisis management
- Crisis management is a process of working through crisis to the point of resolution
- Preventative; crisis avoidance not just resolution
- Establishing and promoting effective communication is fundamental to enabling people to work through crisis
- A crisis provides an opportunity for all to learn
3.WHAT IS THE SERVICE INTENDING TO ACHIEVE?
The North Glamorgan Crisis Resolution and Home Treatment Service has the following aims and objectives:
- To provide through the Care Programme Approach, (CPA) rapid multi-disciplinary community based treatment 24 hours a day, 7 days a week, 365 days per year for people experiencing acute mental health crises for whom home treatment would be appropriate.
- To ensure that people experiencing acute mental health difficulties receive a service that is the least restrictive and, wherever possible, in their home environment (or in a mutually agreed alternative) in order to minimize disruption to their lives.
- To act as gatekeeper for all admissions throughout the 24-hour period in order to ensure bed availability and to facilitate access for those in need of admission.
- Provision of intensive intervention and support in the early stages of crisis, reducing as crisis resolution is achieved.
- To work with Service Users and their Carer(s) to maximise their strengths and potential to recover and stay well.
- To provide multi-disciplinary team involvement enabling a broad range of skills, experience and intervention.
- For the team to remain involved with the Service User and their Carer(s) until the crisis has resolved and/or the person receives ongoing care.
- When inpatient care has been necessary, be actively involved in discharge planning and provide intensive support and treatment at home to facilitate early discharge.
The Crisis Resolution Home Treatment Service (CRHT) has two distinct components:
- A timely response in the form of Crisis Assessment
- Time-limited provision of Home Treatment
4.REFERRAL PATHWAYS / HOURS OF OPERATION
The Crisis Assessment and Home Treatment components of the service are accessed differently.
4.1Crisis Assessment
The Crisis Assessment service is available 24 hours a day. It is accessed by telephoning the Crisis Assessment staff at St. Tydfil’s Hospital. They can be contacted on01685 726337.
The person’s demographic details should be provided along with their current presentation and the factors that indicate an urgent mental health assessment is required.
4.2Home Treatment
When fully implemented the Home Treatment service is available 8am to 9pm 7 days a week. It is accessed by contacting the Home Treatment staff on 01685 726577.
Referrers are expected to provide a copy of the CPA assessment, up to date care plan and risk assessment where available. In the absence of the above, copies of recent documentation must be provided.
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- WHO IS THE SERVICE FOR?
5.1 Crisis Assessment / 5.2 Home Treatment
The Crisis Assessment component of the service is for adults of any age who are in need of an urgent Mental Health Assessment. Urgent is defined as the person presents a risk to themselves or others, or their mental health is at risk of serious deterioration without timely intervention. Referrals are accepted from the following:
- Primary Care
- Police and Court Liaison Team
- Non-Statutory Agencies
- Self Referrals
- Family / Carers
- A & E and other parts of the GeneralHospital (Outside the working hours of the Liaison Mental Health Team)
- Service Users of the CMHTs and Statutory Day Services (Outside the working hours of those services)
- The Duty Officer in the CMHT will try to provide an earlier appointment.
- A Crisis Assessment appointment will be provided if a timely appointment cannot be provided by the CMHT
- The CMHT Duty Officer will fax available information to the CRHT.
- The Crisis Assessment findings and plan will be discussed with the CMHT and sent to them promptly.
A shared agreement regarding what constitutes a ‘crisis’ is problematic because of its subjective nature. The referrer’s working knowledge of an individual’s background enables them, in conjunction with the Service User, family / carer to best identify when a mental health crisis is occurring. With this in mind all Home Treatment intervention requests from the following will be accepted (within service capacity constraints):
- Community Mental Health Teams
- Statutory Day Services
- Staff on inpatient wards
- Assertive Outreach Team
- Liaison Mental Health team
- Crisis Assessor (CRHT)
- Doctors of the Mental Health Directorate undertaking a Domiciliary Visit
- Practitioners undertaking Mental Health Act
There may be flexibility in relation to adolescents between the ages of 16 – 18 years.
- WHO IS THE SERVICE NOT APPROPRIATE FOR?
6.1 Crisis Assessment / 6.2 Home Treatment
- Children or adolescents under the age of 16.
- Those with a primary diagnosis of alcohol or other substance misuse and low Mental Health needs
- Alcohol detoxification in the absence of mental illness
- Primary diagnosis of learning disability
- Mild depression or anxiety disorders
- People who are primarily experiencing a relationship or social crisis in the absence of a mental illness.
- People currently open to the CMHT, Assertive Outreach Team or Day Services (during their working hours)
- People in need of a home / community assessment
- Those people covered in section 6.1 with the obvious exception people in need of a home / community assessment
- People who present with organic disorders – this includes brain damage or other organic disorders such as dementia
- People identified as being in need of low, medium or high security care
7.WHAT DOES THE SERVICE DO?
There are four phases to crisis resolution – assessment, planning, intervention and resolution.
7.1 Crisis Assessment - Assessment & planning / 7.2 Home Treatment - Assessment & planningThe Crisis Assessment component of the CRHT team will provide the following:
- Telephone screening of referrals to ensure the service is the most appropriate for the person referred
- A triage assessment by the Duty Assessor to determine the need for a full assessment for anyone self presenting to the Crisis Assessment Service
- Advice and referral to other services if a Crisis Assessment is not appropriate
- A 4 hour response to accepted referrals, or preferred appointment time as agreed with patient / carer.
- Joint assessment by the Duty Crisis Assessor and a doctor
- A needs led approach to assessment in line with the CPA policy including an assessment of risk.
- Collaboration with Service Users to devise a plan of care
- Summary information to referrer and onward referrals completed within 72 hours of assessment.
- Where it is established that a person referred for assessment is found to be open to the CMHT or Day Services, whenever possible a decision about the need for Home Treatment will be deferred until the existing Care Coordinator can be involved.
- Undertake an initial assessment visit with the Care Coordinator or referrer within 3 hours of referral. Alternatively a preferred appointment time as agreed with Service User / Carer.
- Provide assessment in the Service User’s home wherever possible or, wherever the crisis is occurring, if it is considered to be safe and practical and is agreed with the Service User / Carer.
- Complete an assessment that places Service Users, Family / Carers at the centre of the process as per CPA policy.
- Agree with the Service User and referrer a care plan for CRHT intervention and the date this will be reviewed. A communication plan between the referrer and the CRHT team will also be agreed. Copies of this plan will be provided to all parties’ present and any other agreed people / agencies.
- Update or where necessary complete a CPA assessment and Risk Assessment.
- Devise detailed multi-disciplinary team care plans that will help effectively meet the CRHT intervention plan. These will be devised collaboratively with Service Users and their Family / Carer(s). They must be flexible enough to respond rapidly to changes in the Service Users situation.
The CRHT recognises that in some situations an initial CRHT assessment will not be appropriate / possible as immediate in-patient admission is indicated. In this event the CRHT Practitioner receiving the referral will assist in the accessing of in-patient services. (See section 9 for further information)
7.3 Crisis Assessment - Intervention / 7.4 Home Treatment - Intervention
Following assessment, in some instances the team may arrange further follow up appointments for a person.
These interventions will be:
- Time limited
- Care planned – setting out a clear purpose / aim
- A CRHT Practitioner being identified as Care Coordinator for those people who do not have one elsewhere in the system. The CRHT Practitioner will continue this role until the person is discharged or transferred to a Care Coordinator in another service.
- A CRHT Lead Practitioner being identified for the duration of Home Treatment where the person already has a Care Coordinator / deputy. The existing Care Coordinator / deputy will retain their role and responsibilities.
- Intensive support through frequent contacts / home visits throughout the crisis.
- A range of therapeutic interventions – social, psychological and medical.
7.5 Crisis Assessment - Resolution / 7.6 Home Treatment - Resolution
Discharge planning from the CRHT team will begin early.
For existing Service Users the first review date will have been set during the initial assessment. At this meeting the Service User, Referrer / Care Coordinator will review the CRHT intervention plan and progress towards crisis resolution. If sufficient progress has been made, a discharge plan will be agreed. If further CRHT intervention is indicated the care plan will be reviewed and updated, and a further review date will be agreed. This process will continue until resolution or an alternative intervention is agreed.
Support from the team is time limited, typically a maximum duration of six weeks. In some instances there may be a need to remain involved for slightly longer than this. Before discharge the necessary links between CMHTs / Day Care will need to be restored (existing service users) or arranged (for new people)Where CMHT / Day Service intervention is indicated, but not in place, a CRHT Practitioner will attend the appropriate screening / single point of entry meeting to discuss the referral.
Prior to discharge from the CRHT team, the CRHT Lead Practitioner / Care Coordinator will ensure:
- A crisis and contingency plan has been completed with the Service User and Care Coordinator responsible for ongoing care.
- Coping strategies have been explored with the Service User, Family / Carer.
- Where appropriate a Multi-disciplinary meeting has taken place.
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8.CASELOAD
CRHT Practitioners will have no more than three people on their individual caseload for crisis assessment follow up at any given time. This work will only be carried out at St. Tydfil’s Hospital.
The Home Treatment team will have a caseload of 20 to 25 service users at any one time (frequency and level of intervention will determine). Although Service Users are allocated a Lead Practitioner or Care Coordinator from within the CRHT they will be introduced to and be supported by the ‘team’.
- MEDICAL COVER
The CRHT has two distinct components : crisis assessment and hometreatment. Medical cover for both components is provided in different ways:
Crisis assessment .
Crisis assessment is a 24 hr service and medical cover is provided by either the sector SHO or in their absence the SHO on call.
Home Treatment
The home treatment team has a dedicated Consultant on a part time basis. When a service user in the community is referred to home treatment the RMO responsibility is automatically transferred to the CRHT Consultant unless the service user or Sector Consultant express otherwise.
- WORKING WITH THE IN_PATIENT SERVICE
The CRHT will work constructively with the in-patient service and staff. Admission will be arranged when it is not possible to adequately and safely meet the persons needs in a community setting. When admitting someone the CRHT staff will ensure:
1A purpose of admission care plan is provided at the time of admission.
2A risk assessment is commenced to reflect available information or where a previously completed one is available it is provided.
3A date / time to review the need for admission is agreed with the Service User / family / carer. This should be within 72 hours of the admission.
4The person remains open to the CRHT until the multidisciplinary team agrees otherwise.
5Early discharge is promoted.
Where the CRHT facilitates an admission for a Service User open to another part of the Mental Health Service, it will be expected that the person has been reviewed (seen in person) within the previous 48 hours. It will be considered ‘best practice’ for steps one and two outlined above to be followed. Step three a date / time for a review of the admission will be agreed. The CRHT service will participate in this review enable the promotion of a timely discharge.
11. Working with community teams
The CRHT will work constructively with the CMHT in order to provide a whole systems approach to working with service users. As previously described, the home treatment model places the care coordinator at the heart of decision making and if at all possible, the commencement and cessation of home treatment intervention will be undertaken withina CPA review, with a full and open discussion with all parties. Attached is appendix 1 – Guide for referring into home treatment and appendix 2 – CPA procedure for home treatment.
12.Bed management
The CRHT will have sole responsibility for the management of beds. The ability to manage beds relies heavily on the acquisition of accurate bed numbers and this will be facilitated through the twice daily liaison between the CRHT and the 3 wards to establish how many beds are vacant and who is on leave.
In order to manage beds effectively, it is important that all admissions are directed through crisis. This will ensure, the CRHT know who is being admitted and how many new admissions the ward are able to absorb.
Previously, the process for admission has been through the ward managers. i.e. the CPN / social worker/ Consultant wouldphone the ward and discuss admission. With the introduction of the CRHT, the process has changed:
If the community worker identifies the need for a bed, the CRHT practitioner should be contacted to discuss