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

BEHAVIOURAL THERAPY

SOCIAL WORKERS

PSYCHOLOGISTS

NURSES / CPN

FAMILY THERAPY

ADDICTION COUNSELLORS

REFERRING AGENTS

Monaghan

CavanCarrickmacross

Bailieborough

COMMUNTIY REHABILITATION TEAM (POP. 119,000)

PSYCHIATRY OF LATER LIFE

ADDICTION SERVICES

Community Mental Health Team

Community Mental Health

Team

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-usersWith Carers/Families/Significant othersWith G.P’sReassuranceAction

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

SERVICE USER

CPN

Acute inpatient

Admin

Addiction

Family Therapy

H.B.T.

Medical Secretaries

S.W.

Psychology

O.T.Behavioural Therapy

Medical Team

Management

Health promotion

Education

Women’s Groups

Voluntary groups

Eemployment

Housing

Advocacy

Solas

GardaíCommunity Care

Primary care

Self Help

Youth Groups

Community

Service user

Family / carers

Mental health professionals

Primary care / social services

Voluntary / statutory organisations

National community

Community Mental Health Teams

Monaghan

CavanCarrickmacross

Bailieborough

COMMUNTIY REHABILITATION TEAM (POP. 119,000)

PSYCHIATRY OF LATER LIFE

ADDICTION SERVICES

Community Mental Health Team

Community Mental Health

Team

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

M O N AG H AN C AVAN C O M M U N ITY M EN TAL H EALTH TEAM

H .B .T . / A C U TE IN P A T IE N T

P S Y C H IA T R IC E M E R G E N C Y M U L T ID IS C IP L IN A R Y T E A M

T E A M C O -O R D IN A T O R

P R IM A R Y C A R E

COMMUNITY REHABILITATION TEAM

Clinical

Coordinator

CPN

Acute inpatient

Admin

Addiction

Family Therapy

H.B.T.

Medical Secretaries

Social Worker

Psychology

O.T.Behavioural Therapy

Medical Team

Management

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 ofHome 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

EmpowermentInformation

Choice

Decision Making

ControlResponsibility

Accountability

Self Value

Self Esteem

Confidence

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

service-user/family/HBT and medical staff Contractual arrangements with service-user and family/

carers agreed.

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

www.face.eu.com/our-products/assessment-tools/mental-health-assessment-toolset

Service-user and relatives are also given verbal and written educational/self-help information

Liaises closely with medical staff

and team leader. HBT liaises with other disciplines to ensure follow up care after discharge

HBTT meetings twice weekly

HBTT Nurse Then:

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 intensivealternative days, twice weekly

•Continual Careonce weekly/fortnightly

HousingEmployment

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

GP DetailsPersonal details Affix label here

key worker's): Consultant;

referral details

treatment to date

ICD 10 Diagnosis

medications on discharge

discharge plan

SERVICE USER

CPN

Acute inpatient

Admin

Addiction

Family Therapy

H.B.T.

Medical Secretaries

S.W.

Psychology

O.T.Behavioural Therapy

Medical Team

Management

Health promotion

Education

Women’s Groups

Voluntary groups

Eemployment

Housing

Advocacy

Solas

GardaíCommunity Care

Primary care

Self Help

Youth Groups

EVALUATION

Overall feeling about the cooperation between service providers

Mostly Dissatisfied

5%

Mostly Satisfied68%

Excellent27%

Mostly Dissatisfied Mostly Satisfied Excellent

Overall view of confidentiality and respect shown for clients rights

0

10

20

30

40

50

60

70

terrible mostly dissatisfied mixed mostly satisfied excellent

perc

ent

GP CARER CLIENT

Overall level of satisfaction with the service.

0

10

20

30

40

50

60

70

GP Carer Client

Mixed Mostly satisfied Excellent

The response of the service to crsis or urgent needs.

0

10

20

30

40

50

60

70

Patient Carer GP

Mixed Mostly Satisfied Excellent

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

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Copyright - Cavan Monaghan Mental Health Service

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

THANK YOU

WHAT FACILITATES RECOVERY ?

15% 30%

15% 40%

T O P D O W N SU PE R V ISOR Y C O NT R O LM IN IM A L N E E D FOR D ISC R E T IO N

R E LIA N C E O N R U LE , JOB SPE C IFICR IG ID , LIT T LE INFLU E N C E

T R A D IT IO NA L ST Y L E

MANAGEMENT STYLE

LEADERSHIP MANAGEMENT STYLE

M O T IV A T IO N , IN N O V A T IO N , C R E A T IV ITYO P E N T O C H A N G E , JO B S A T IS F A C T IO N

R E D U C E D D E M A N D S O N M A N A G E M E N T T IM E

F L E X IB L E , C O M P E T E N TA U T O N O M O U S , D E C IS IO N M A K IN G

S H A R E D P L A N N IN G , R E S P O N S IB IL IT IE SA C C O U N T A B IL IT Y A N D O U T C O M E S

T E A ME Q U A L IT Y , C O L L E C TIV E , C O LL A B O R A T IV E , C O M M U N IC A T IV E

(W o rk in g )

H O R IZ O N T A L

CitizenshipRecoveryRiskLeadershipBeliefEngagement Thinking outside the boxOrganisational CultureManagement horizontal versus BureaucraticOver managedAutocraticMutual RespectCollaborationPartnership