Standard Operating Procedure for Access to Early Intervention Services
Document author / Assured by / Review cycle
Director of Operations / 3 years
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Contents

1.Overview

1.1Purpose

2.Access procedure

2.1Principles

2.2Referral Criteria

2.3Assessment Process (In line with NHSE 2015b)

2.4Carers, Family and Friends

2.5Non engagement

3.Access standards

3.1Hours of Operation

3.2Waiting Time and Assessment Standard – Entry to the Service

3.3Interventions

All Standard Operating Procedures are aligned to Trust strategies and policies, found in the Board Document Library, and must be executed within the parameters set by such documentation.

Standard Operating Procedures are supported by local procedures defined in each locality. These are found on the locality pages on Ourspace.

1.Overview

The experience of psychosis has a profound affect on the individual concerned, their family and friends. A first episode of psychosis usually occurs in adolescence or early adult life and can be described broadly as a disorder leading to a distortion of or loss of contact with reality. The most common experiences are hearing voices when there is no one talking and extreme feelings of paranoia. Psychosis develops during a critical developmental period and so can affect all aspects of life – education and employment, relationships and social functioning, physical and mental wellbeing (DoH 2001)

1.1Purpose

The Early Intervention Teams ensure individuals experiencing a potentially emerging (At Risk Mental State – ARMS) or actual first episode of psychosis and their families receive effective help based on the following principles:

  • Immediate engagement is made with individuals and/or their families as soon as psychosis is suspected/identified.
  • Provision of a formulation driven evidence-based package of care for up to three years.
  • Reduce the duration of untreated psychosis of people referred to Mental Health services in the Trust.
  • Provide a service for those within the age range of 14 – 35 currently based on NICE Children and Young People (CG 155 NICE 2013) or Adults (CG178 NICE 2014) guidelines depending on age and working towards full implementation of ‘Ageless Service’ aspiration range of 14-60 within next 12 months
  • Make effective links (such as Transitions Services, Link Worker roles) between child and adolescent mental health (CAMHS) and adult services to facilitate an effective service delivery for a team which straddles these traditionally separate services.
  • Increase stability in the lives of service users, facilitate development and opportunities for personal fulfilment.
  • Develop links with Primary Care Services and other key agencies, offering education and support with the aim of facilitating early identification of psychosis.
  • Develop links with key agencies e.g. Education, Social Services, Dual Diagnosis, Housing, Youth and other non-statutory services
  • Actively utilise all opportunities and ‘medium’ to reduce the stigma associated with psychosis and improve professional and lay awareness of the symptoms of psychosis and the need for early assessment.
  • Ensure that care is transferred thoughtfully and effectively at the end of the treatment period. Treatment will usually last for up to 3 years but can be shortened or extended depending on clinical need

2.Access procedure

2.1Principles

The Early Psychosis Declaration (Edwards & McGorry 2002, Newcastle 2002) and updated IRIS Guidelines (IRIS Network 2012) outline the following principles to be of key significance when developing early intervention services. Services will be based on and aspire to these principles:

  • Culture, age and gender sensitive
  • Family, friends orientated
  • Meaningful and sustained engagement based on assertive outreach principles
  • Treatment provided in the least restrictive and stigmatising setting
  • Emphasis on normal social roles and the service user’s development needs, particularly involvement in education and achieving employment
  • Emphasis on formulation and managing symptoms rather than diagnosis

2.2Referral Criteria

To be referred to the service an individual must meet the following criteria:

  • Age range 14 - 60 years

-EI Team structure varies across the Trust in terms of how they work with CAMHS services. Some clients are cared for by the local CAMHS service and the EI team notified of their existence. Other EI teams have embedded CAMHS workers and therefore CAMHS clients are seen by them, though they are also seen by Consultant Psychiatrists and Psychology within the local CAMHS service. In this latter case, Service Users are referred to the team by the CAMHS service in the same way that Adult clients are referred by the Recovery Teams.

  • Have a GP within the locality of the relevant EI service.
  • Evidence of positive and/or negative symptoms of psychosis or concerns about the early signs of psychosis developing (ARMS part of Service). Note: A formal diagnosis is not necessary for referral.
  • Evidence of a marked reduction in social and/or occupational functioning or other ‘at risk’ indicators
  • Referrals accepted from any source with GPs being kept informed if not from Primary Care
  • If already had/in contact with Adult Mental Health Services, this should have been for other problems of a ‘non-psychotic’ nature such as anxiety/depression and where current referral for Psychosis is a new emerging phenomenon. If the Service User has been on anti-psychotic medication for another condition for over 12 months the referral will not usually be accepted. But exceptionally when it can be shown that a ‘low dose’ regime has been used this may be accepted on a case by case basis

2.3Assessment Process (In line with NHSE 2015b)

  • Screening

A screening tool may be used to help determine the possible presence of positive and/or negative symptoms of psychosis. This has been developed for referrers from non-statutory agencies who routinely deal with high levels of emotional distress and disturbance. Also for statutory agencies, where Psychosis is rarely seen such as CAMHS services.

  • Assessment Tools

The service attempts to avoid duplication of assessments and therefore, the Trust core CPA assessment will be used with all clients as part of the initial assessment. Certain specialist assessments will then be employed as part of a more detailed and structured assessment process. These tools are used at entry into the service and then (at least) annually until the client has completed their 3 years with the service. The specific assessment tools used are:-

-Positive and Negative Symptom Scale (PANNS) This tool can be substituted for either the Krawiecka, Goldberg and Vaughn (KGV) or Comprehensive Assessment of At Risk Mental States (CAARMS) mental state assessment.

-Global Assessment of Functioning (GAF)

-Drake Substance Misuse Scale

-DIALOG (Priebe et al 2007)

-Process of Recovery Questionnaire (QPR) (Neil et al 2009)

  • Extra essential Information

-Core GCSE status

-Baseline and 12 month employment status (IPS)

-Other tools are also used as clinically indicated in addition throughout the period of care, for example the Engagement Measure and HoNOS PBR/Cluster Allocation Support Tool.

2.4Carers, Family and Friends

(Note: The term carer applies to family and friends also in this section)

All carers of users of the Trust’s services (service users) are entitled to an assessment of their own needs. The existence of carers will be identified at the initial service user assessment or earliest opportunity by the AWP assessor.

As part of the assessment process when clients are referred, the service will make a point of speaking with carers to gain a more holistic understanding of how the presenting problems have impacted on the people around them. Verbal and written information will be provided about First Episode Psychosis and about the Early Intervention service, including the process around the initial assessment.

Carers will be sent an ‘Early Intervention’ Carers pack within a week of being identified; this will include information about accessing carer’s assessments/support, web resources and current information about First Episode psychosis.

For carers of clients accepted into the Early Intervention Service, a Carers assessment or review appointment will be offered either as part of a service user care plan. . Carers may decline this appointment or review, but will be offered the opportunity to meet for a review as long as the client remains open to the team. In addition to this, depending on the individual client’s situation/circumstances including the needs of the carers, formal Family interventions should be offered which will involve a co working model and structured sessions, often in the Family home. If this offer is taken up, two initial assessments are carried out with Carers. These are:

  • Relatives Assessment Interview (Short RAI)
  • Knowledge about Psychosis inventory (KAPI)

Other assessments and psycho educational tools will then be used depending on the outcome of these assessments as part of the ongoing family work sessions.

Carers will be offered an opportunity to attend Education sessions or Carers Education and Support sessions as part of family interventions or as a single intervention.

Where Carers do not take up the offer of an appointment for assessment or review , or are assessed as not needing support, information or services, this will be reviewed by the Care Coordinator at each review of the service user’s care.

2.5Non engagement

The literature suggests that a strong therapeutic relationship forms the basis of engagement with services and is a significant factor in predicting longer term outcomes (McCabe & Priebe, 2004). In order for the full range of effective interventions to be offered by an EIS a collaborative, trusting relationship has to be developed (Tait et al, 2010). Factors which have been identified as supporting engagement include workers offering support without focusing on medication, working in partnership and offering time and commitment (Priebe et al, 2005). It is important to acknowledge that engagement difficulties can reflect a problem with the services being offered as much as with the individual concerned (Tait et al, 2010) so EI Teams work in a multidisciplinary way to offer a range of avenues to engagement.

In a situation where a person refuses to have contact with the team either for assessment or ongoing treatment, the team will adhere to the following process:

  • Convene a Care Plan Review to ensure that every avenue has been explored regarding engagement. Consider consultation/advice from a relevant external specialist to the Team and the original referral source if in the assessment phase. Documentation from the review is circulated to all relevant parties
  • Undertake a multidisciplinary risk assessment to determine appropriate courses of action including if a Mental Health Act assessment is required for the safety of the person or others.
  • Make every effort to negotiate some on-going contact even at a monitoring level.
  • Involve the family and any 3rd sector provider (e.g. housing)
  • If discharge from the service remains the only option, utilise the Rapid Access process (CPA policy 2013). Ensure that EWS and actions are clearly documented. NOTE: The discharge and rapid access plan may include on going contact with the persons family

3.Access standards

3.1Hours of Operation

The core working hours for contacting the service are Monday to Friday 9.00am to 5.00pm but the team work flexibly beyond these hours to address individual and carer need.

Out of hours service provision is provided via the Crisis/Intensive Service. This support team is for Service Users who require additional support to stay in their own homes during a crisis or to facilitate an early discharge from hospital where clinically indicated.

3.2Waiting Time and Assessment Standard – Entry to the Service

Early Intervention Services take referrals from any source (DH, 2001). This includes self referrals, those from carers, GPs and Primary Care Liaison Services, Non- Statutory agencies, schools, universities as well as from secondary care mental health services, such as Recovery Teams and Inpatient Units. The EIPS work within the World Health Organisation’s definition of Psychosis:

‘Psychosis’ is a set of symptoms that can be evident in a range of mental health problems, including those diagnosed as ‘manic depressive psychosis’, ‘bipolar affective disorder,’ ‘schizophrenia’ and ‘paranoid schizophrenia’. The term refers to a disturbance in a person’s thinking that divorces them from their surrounding reality. This disturbance is often manifested in distorted perceptions (hallucinations), delusional (paranoid, grandiose and depressive) ideas, disorganised speech patterns, and intense mood fluctuations.’

Access to the service will be regardless of referral source, co-morbidities such as learning disabilities, drug misuse, personality disorder or autism. The only exemptions from this will be for referrals of people who are experiencing psychotic symptoms with a medical or surgical cause such as Huntingdon’s or Parkinson’s disease, HIV or syphilis, dementia or brain tumours (NHSE 2015a)

Informal discussion with the team is actively encouraged (by phone, email or face to face) for potential referrals wherever possible. Once a referral for psychosis has been received by the Trust the Waiting Time Standard will apply in all cases

It is recommended that all EI Teams have a dedicated Consultant Psychiatrist but until all the teams have their own dedicated Consultant Psychiatrist, specialist prescribing will be undertaken by an Independent Nurse Prescriber, the appropriate Recovery Team Consultant or the GP, and will be determined on an individual, needs led basis depending on the referral route.

Where the referral is received from a Recovery Team and the client is on their caseload, Care Coordination will remain with the originating team, until it has been established that the Service User has a first episode of psychosis. The referral will be no greater than 2 weeks, from diagnosis of psychosis to provision of Nice Compliant Package of Care (NCPC) in line with WTS (NHSE 2015b).

A Nice Compliant EIP Service is able to offer and deliver the following NICE recommended treatments to >50% of people within 14 days of referral:

  • Cognitive Behavioural Therapy for psychosis
  • Family Interventions
  • Clozapine therapy (if 2 antipsychotics have proven ineffective)
  • Education and Employment (IPS) Support
  • Physical Health Assessments
  • Wellbeing Support (eat healthily, physical activity, smoking cessation support)
  • Carer focused education and support

3.3Interventions

Should service users require ‘crisis’ or in-patient care during their time on the caseload, the EI Team will work jointly with the Crisis/Intensive Teams to assess the need and define the care package.

In-patient stays should be avoided where possible but where they are unavoidable the EI care coordinator will remain in (at least weekly) active contact with the client and work with the ward team to provide continuity and support for the transition back to community care. Continuity of care is essential throughout admission.

Version History
Version / Date / Revision description / Editor / Status
1.1 / November 2008 / Finalised as part of Early Intervention Services Operational Policy / NA / Draft
1.2 / June 2010 / Transferred into new format for Access procedure / Mandy Reed / Draft
1.3 / 7 July 2010 / Final version / MR/PB / Final
1.4 / November 2010 / Revised transitions/non-engagement / MR / Final
2.1 / July 2014 / Update Revision / AL / Draft
2.2 / October 2015 / Redraft update following introduction of WTS / AL / Draft
2.3 / 18 December 2015 / Completed revision / AL / Draft
2.4 / 23 December 2015 / SOP copied to new template, reviewed and revised. For further consultation. / AL / Draft
3.0 / 09 May 2016 / Approved for publication by Director of Operations / AL / Approved
Standard Operating Procedure for Access to Early Intervention Services / Expiry date: 09/05/2019 / Version No: 3.0 / Page 1 of 7