Devon PartnershipNHS TrustMind the Gap – SCFT

Devon PartnershipNHS TrustBackground

• 5 years working in large CFS with NottsHC

• Recently moved to Devon to help set up new “SCFT”

• Pilot site funded by NHSE, awarded £1.2m, with £600k to be kept for social care costs

• Will outline the model for this, as well as some of the key issues in community forensic work

Devon PartnershipNHS TrustAims and Objectives of SCFT

• Help define and actively facilitate care pathways from secure care to the community

• Evidence based case management and treatment

• Improve interfaces and communication between stakeholder agencies

• Co-production with accommodation providers to support transitions and develop services

• Maximise patient safety and public protection

• Develop peer support network and employment opportunities

• Embed patients in their communities

Devon PartnershipNHS TrustAims and Objectives (Put Simply)

• Patients discharged from secure care faster, more safely, and maintained in better overall health

• Achievable through really knowing and understanding our patients from a relational perspective

• Target is to save 7 beds a year/45 patients out over 2 years

Devon PartnershipNHS TrustDevon SCFT-The Team

• Pilot Project

• Consultant Psychiatrist+8a Service Manager

• 8C Psychologist

• Band 7 CTL

• 2x Band 6 CPN

• SW/AMHP

• Peer Support Worker

• Band 4 Admin

Devon PartnershipNHS TrustClinical Model-Relational Approach

• Relational/procedural security even more important in community due to absence of physical security

• Violence occurs within the context of relationships: past and current relationships need to be understood to prevent future violence

• Relationships are two way-relational approach requires team(s) to examine their contribution to relationship (cf. attachment model)

• Quality of the relationship between patient and the SCFT, and the SCFT and partner agencies will be crucial to success

• Emphasis on simple terms, concepts and clarity

Devon PartnershipNHS TrustSequencing of Care

• Sequencing central to role of SCFT

• 1st Steps: Referral, Assessment, Formulation

• Distinct Treatment phases: Pathway care management – Indirect and Direct; Community Case Management; Transition out of Forensic Care (if appropriate)

• Clarity re roles and responsibilities crucial

• What do patients need to demonstrate for discharge?

• What needs to be done in hospital? (What doesn’t..?)

Devon PartnershipNHS TrustPatient Journey

• Insert patient journey brochure graphic

Devon PartnershipNHS TrustPhase 1-Transition to Community

• MDT to determine whether “active” or “indirect” –active usually approx. 6/12 from discharge

• Indirect-develop formulation, identify barriers and timescales, facilitate/monitor progress through attendance at eg CPAs and remote work

• Active-SCFT become lead for transition. Direct contact, weekly. Discussed weekly. Additional interventions as req. Leave used to attend Moving On group and peer support network. Community Gatekeeping Risk Assessment.

Devon PartnershipNHS TrustGatekeeping -10 point risk check list

• Optimisation of mental state (not necessarily symptom free)

• Sufficient insight to adhere to treatment plans or robust enough framework to ensure compliance and detect any deterioration

• Clarity around early warning signs, triggers and relapse signature

• The community team have developed and shared the patient formulation and crisis plans with relevant agencies

• Patient well engaged with SCFT, utilising unescorted leave, and community network

• Sufficient relational/procedural security to manage patient outside hospital

• Appropriate legal frameworks considered e.g. CTO, SOPO

• Appropriate victim liaison has been undertaken

• Risk management liaison undertaken e.g. MAPPA/MARAC/CHANEL/PREVENT

• For restricted patients-MoJ in agreement and patient has completed Conditional Discharge package

Devon PartnershipNHS TrustMind the Gap-The Cliff Edge

• Helping patients (and others) understand and prepare for stepping off the cliff edge from the highly structured, supported, safe and immediately responsive environment of the secure unit is one of the most important tasks

• Patients and other teams/agencies often underestimate how challenging this step over the edge can be, in both the short and long term

• It is a high risk time and if earlier discharges are to be successful, the team must know patient well

Devon PartnershipNHS TrustPhase 2-Community Treatment and

Support• Structured case management under CPA, +/- other

interventions as appropriate

• 3 patient streams-LT maintenance; further community Rx/risk reduction; transitioning out of secure care to mainstream services

• Psychological therapies (group and individual)

• Offence specific work

• Sequenced social recovery, IPS

• Peer mentoring

• Clubhouse

• Systems support-consultation, training and supervision

Devon PartnershipNHS TrustReality of Treatment

• “I didn’t really start thinking about myself until I was out”

• In secure care, patients (and teams) often focussed on “getting out”

• Initially, patients often feel all the work is done

• Once out and they re-encounter familiar difficulties, there is an opportunity for meaningful, voluntary engagement of a different quality

• If patients can be engaged in work on themselves at this stage there can be tangible benefits to quality of life, relationships…and risk profile

Devon PartnershipNHS TrustDifficult Situations-4Ds

When to….

• Detain?

• Disclose?

• Discharge?

• Do nothing?

• Relational understanding and clarity around roles/responsibilities are key to managing well

Devon PartnershipNHS TrustSystemic Health

• Relational approach underpins all interventions

• Clear team structure with clarity of roles/remits, co-located within established LDU. No “smart working”

• Emphasis on clear, concise communication

• Clear protocol for managing all transitions into and out of service

• Universal team diary with regular direct contact, supervision, external peer review, reflection and mechanisms for emergency MDT meetings

• Maintain good relationships with partner agencies and ensure good flow of information and feedback

• Provide supervision and training to support placements

Devon PartnershipNHS TrustCrisis Management

• Crisis plan (developed with patient): guidance on who/how to contact when concerned

• Risk assessment and formulation + front page summary

• Bed management/referrals meeting and crisis teams to be kept aware of all “hot cases”

• Crisis reviews will ordinarily be in a secure community environment.

• During Hours-Clear initial point of contact. Central phone number. Same day MDT discussion and action plan

• Out of Hours-Crisis team/CJL liaise with forensic on call consultant for further advice. Follow protocol for emergency admission if required.

Devon PartnershipNHS TrustPhase 3-Transition out of Forensic

Services• Early involvement of local teams to facilitate relational

understanding of patient and risks

• Early liaison with partner agencies to support process

• Time limited consultation and supervision to receiving teams, following discharge from SCFT

• Development of peer support network and Clubhouse for patients to continue to use post discharge from SCFT

• Transition relationships out of the forensic/mental health network; embed patients in their communities

Devon PartnershipNHS TrustHousing Strategy

• Right accommodation and support a big issue

• Initially will make use of existing structures/resources

• Connelly House-OT facilitated, forensic pre-discharge unit, beside community forensic base. Aim to develop OT outreach and support to other providers to roll out this model of step down care

• In discussion with a number of providers to develop forensic-specific step down accommodation

Devon PartnershipNHS TrustSocial Care Model

• 3 potential models:

• 1. Pay for first 4 months of placement for all patients to accelerate discharge (1month trial leave +3 months)

• 2. Reduce to 3 months total and have some reserve for “one-offs”

• 3. Use funds for high cost bespoke placements for small number of patients who may not otherwise be able to transition

Devon PartnershipNHS TrustWhat is Success?

• Reducing Length of Stay, Risk, Morbidity

• Important to also collect measures of health cf. measures of illness/risk

• Culture shift across the pathway an important “side effect” of CFS?

• Meeting to discuss data collection centrally on 6th July

Devon PartnershipNHS Trust