West Fife Community

WEST FIFE COMMUNITY

OUTREACH TEAM

Promoting Recovery in Mental Health

WEST FIFE COMMUNITY OUTREACH TEAM

The Community Outreach Team started life as the Continuous Community Treatment Team in March 2000. We continue to provide a community service for people with severe and enduring mental health problems.

Although the name has changed, the key features and aims remain the same.

KEY FEATURES

·  Providing a community service for a defined client group.

·  Providing a service 7 days a week, 365 days a year.

·  A composition of training staff, Support Workers and administrative staff.

·  Dedicated Consultant Psychiatrist sessions.

·  Case Management/Assertive Outreach.

·  Integrated and close links with voluntary/statutory agencies.

AIMS

·  Lesson or eliminate the debilitating symptoms of mental illness each individual client experiences and to minimise or prevent recurrent acute episodes of the illness.

·  Improve social functioning in adult social and employment roles/activities.

·  Social prescribing.

·  Work in partnership with users/carers.

The West Fife Community Outreach Team consists of:-

·  Team Leader

·  Six Clinical Care Managers

·  Six Support Workers

·  Consultant Psychiatrist

·  Specialty Doctor in Psychiatry

·  Clinical Psychologist

·  Senior Occupational Therapist

·  Occupational Therapy Assistant

·  Two secretarial staff

The Team Leader and Clinical Care Managers have come from a variety of backgrounds e.g. Mental Health and Social Work.

REFERRALS

Referrals come from locality mental health teams / secondary care, and they originate from Consultant Psychiatrist, OT Service, CPN Service, Psychology and Social Work. We have 135 clients at present and on average receive 2 new referrals per month. We provide a service to a further 92 clients who are not with the Team but who attend the Depot Clinic and Affective Disorders Clinic.

DEPOT CLINIC

We run 3 depot clinics per week with a total of 58 clients attending. Thirty-two of these clients are with the West Fife Community Outreach Team. The remaining clients are seen through the Continuing Care Clinic.

In addition to administering depot injections, we assess the clients’ mental state and refer them to other agencies if needed. We also have 28 clients who receive their depot injection at home as they are unable to attend the clinic.

AFFECTIVE DISORDER CLINIC

One Clinical Care Manager and the Specialty Doctor in Psychiatry run the Affective Disorder Clinic every Monday morning.

Seventy-three clients are registered with the clinic. We aim to see these clients every 3 months.

Bloods are taken to measure Lithium levels every 3 months and full blood counts are taken every 6 months, sooner if needed.

We monitor and assess the clients’ mental state.

We encourage the clients to participate in doing a Relapse Signature.

We Provide education about their illness and about their medication.

We can refer to other agencies if needed.

TREATMENTS AVAILABLE INCLUDE:-

PSYCHOLOGY

Dr Amy McArthur is a Clinical Psychologist who works with the Team to develop psychological approaches with the Team and its clients. This often involves taking referrals for 1:1 assessment and psychological treatment as well as involvement in running groups. It can involve working indirectly by providing consultation and psychological advice to other staff to assist them in their work with clients.

OCCUPATIONAL THERAPY

Occupational Therapy is integrated within the Team, and is community rehabilitation orientated, with the aim of developing independence in individual’s occupational performance of day to day and community living skills, developing variety and balance within regular roles and routines whether that be domestic, leisure or vocational in nature. Identifying and supporting participation in client led interests, increasing social opportunities and exploring and developing the coping skills required to sustain improved community functioning whilst maintaining optimum health. Rather than supporting clients to make changes, input focuses upon ways to make changes sustainable.

Occupational Therapy and the Clinical Care Managers from the Team work closely to establish co-ordinated treatment plans and there are shared roles fulfilled with clients including education, relapse prevention, health promotion and general support.

Occupational Therapy offers both 1:1 treatments and is activity based.

Specialist function assessments are used routinely to develop plans and input and measure change in the clients occupational functioning of day to day tasks and also to measure how clients perceive their own functioning.

There is one wte OT, supported by a dedicated 0.2 wte OT Support staff member. The generic Community Support Workers are also utilised to carryout Treatment Plans. OT is available Monday to Friday 9am – 5pm, although many of the activities clients are engaged in happen within the West Fife Community Outreach Team, working hours via the Community Support Workers.

OTHER FORMS OF ENGAGEMENT

·  We also monitor and assess the client’s mental state.

·  Provide education re illness and medication.

·  Complete Relapse Signatures with the clients.

·  Regular out-patient appointments with their Consultant Psychiatrist.

·  Home visits by Consultant Psychiatrist and Specialty Doctor in Psychiatry.

·  Assistance to attend appointments, shopping, paying bills, moving home, correspondence or anything else that they may need to maintain their tenancy or keep mentally well.

GROUPS

We have run various groups throughout the years according to the clients’ wishes. We are currently running a Walking Group and an Allotment Group. We have, in the past, facilitated a Swimming Group, Badminton Group, Women’s Group and Social Group. We are in the process of developing educational groups on Bipolar Affective Disorder and Schizophrenia.

The West Fife Community Outreach Team maintains and develops a holistic approach. We believe that social needs are very important and that social prescribing not only has a positive impact on the client’s mental state and physical health but it also helps to improve their quality of life through social integration. We assist the clients to access local amenities such as:

·  Gym

·  Swimming Pool

·  Library

·  College

·  Cinema

·  Exercise Classes

·  Slimming Group

·  Church

·  Museums / Art Galleries / historical buildings.

·  Golf range

·  Archery Club

·  Local markets

These are only a few of the activities however, we will assist the clients to attend any hobbies or activities that they are interested in.

ENGAGEMENT WITH OTHER AGENCIES

We continue to develop relationships with both statutory and voluntary agencies e.g. SAMH (Scottish Association for Mental Health), Supporting People, Community Police Officers, Housing Services, CARF (Citizens Advice and Rights Fife), Going Forth, Boomerang Association, Circles Network and Social Work.

We participated in the development of the Scottish Recovery Indicator and recently used it at our Development Day to reflect on our practice. We identified a lot of good practice and were able to highlight areas for development.

Feedback from clients was obtained using group interviews and was very positive.

Some examples:

·  “Care Managers help you to get in touch with the right people”

·  “Through the CPA (Care Programme Approach) it was identified that medication was making me out on weight. This was acted on accordingly”

·  “Staff noticed physical problems before the service user did”

·  “Staff were supportive”

·  “Staff were very informative, service users not always aware of benefits and entitlements”

·  “When severely depressed and unable to deal with personal care, staff helped me to be more motivated”

·  “Personal comments from carers to Care Managers have included a mother who stated that we have managed to get her son to a level that he can live at home without previous problems, such as aggressive behaviour. She now feels that she has her son back and has felt supported by the Community Outreach Team and medical staff. She was also referred to Fife Family Support.

We attempt to engage appropriately, with permission with clients’ families who are frequently involved in Care Planning and CPA meetings.

SUPERVISION

Clinical Care Managers and Support Workers are supervised through Clinical Supervision, Clinical Care Managers and Support Workers meetings, and 1:1 meetings with the Team Leader.

TRAINING AND STAFF DEVELOPMENT

Training and staff development remain integral to the service. We all attend mandatory training events and organise in-house training from other agencies such as Transgender Workshops, Vulnerable Adults and Illicit Drug Use.

The Clinical Care Managers provide teaching sessions for the Support Workers on severe and enduring mental illnesses, medication and possible side effects.