Skibb/Schull/Mizen

Bantry, Ctb, Sheep’s Head Head

Clon/Dway/Ballineen

West Cork Catchment Area

SERVICE DEVELOPMENT

AGENDA

COMMUNITY DEVELOPMENT

AGENDA

USER VOICE:RECOVERY

AGENDA

Mental Health Agenda

Well established Community focus and links – West Cork Carers, National Learning Network, Rehab Care, Employability, Co-Action

Home Focus Team (with NLN) have a recovery focus on training and has support from recovery mental health worker

Attitudinal change within own Service

Recovery document “Moving WCMHS in a Recovery Direction” – disseminated to staff in 2011; Arts/Health MH Coordinator Pilot Project

User, Carer and Advocate involvement within our service a priority over past 8 years

‘Windows’ Group in 2009 - engaging with individuals interested in improving our Mental Health services. The group have formed a good working relationship; developed a comprehensive on-going agenda whereby the existing services and external agencies can improve the treatment/care being delivered to the people of West Cork; carers have attended Management meetings; renamed the Psychiatric Unit “Centre for Mental Health Care and Recovery.”

Collaborative working with Users, Carers and Service Providers in DCU Leadership programme - 4th year in West Cork. Throughout this process we have identified needs and have implemented:

Trialogues, a group for family & friends of those in mental distress, an Open Dialogue’ training for family work in community.

‘Genio’ funding - Recovery Bus, Recovery worker for one year in community; p/t Family worker for one year to help with family work project

This gap in service identified in early 2005

Reason: Relatively high turnover of Medical, Nursing and MDT staff

On-going issues – 6 month rotation of NCHD’s, plus internal

rotation of NCHD’s between teams.

User feedback

GP Frustration: No one consistent approach and contact

Changing the nature of day to day interactions and the quality of the experience for the service use

Needed single point of access

The West Cork Mental Health Service is also involved with community organisations, voluntary sector organisations and individuals from West Cork

An informal network of stakeholders who provide community supports for people with mental health problems

It provides a channel for service users, identifies support for families and engages with the local community to challenge the stigma of mental illness.

A large community event is arranged around the time of World Mental Health Week. This deepens collaboration with all the other stakeholders in the area and with the local community in the debate about mental illness and our response to it.

Mad Pride Event last year, one planned 2012

Local

Management Business Mtg

National Learning Network/Rehab

Care

GP/Primary Care Teams

CNS Counselling/ Psychotherapy

ANP/Family Therapist in

Primary Care/MH

West Cork Carers Support Group

Employability

Collaborative Learning DCU Windows

Community Mental Health

Forum

Centre for MH Care and Recovery

TEAM WORKING

CROSS-FUNCTIONAL

WORKING

Team Co-ordinator

SERVICE USERCarer

Team working/cross functional working

Home Focus Team

The clinical function of our team is managed by the Team co-ordinator. This includes:

the triage of referrals liaising with GP & primary care professionals chairing sector team meetings/support team to

work in a multi-disciplinary way liaising with community agencies (including

Service Users &Carers) clinical/management role

Non-urgent referrals are sent to Team Coordinator / Consultant and discussed/ triaged at team meetings (the single point of entry as described in VfC)

Urgent referrals are by phone/fax from GP’s to Team Coordinator/ NCHD’s (out of hrs-on call NCHD);TC helps to facilitate urgent referrals.

Advice on referral pathways for GP’s, service users & carers, and other agencies in community

The administration and triage of referrals in consultation with Consultants and teammembers

Telephone advice for GP’s & other primary care professionals on potential referrals and existing users

Follow up on referrals/’chase’ referrals Available to PCT clinical meetings or case confs.

This approach has led to: Improved & more positive relationships with GP’s in

West Cork A more fluid communication of information between

PCT and mental health service A more efficient pathway for referrals

Referral by GP/Other member of PCT

Single point of Entry to CMHT

Identify Mode of Assessment, e.g. urgent r/v, home visit, outpatient clinic or other (ie counselling)

Identify Team members to complete Assessment.

Assessment

Outcomes: Signposted to another agency

Advice given and discharged back to GP

Treatment offered – Therapy/Social/Medication/Inpatient/Outpatient/Other

Referral passed to CBT/Psychology/Psychotherapy Services/Social Worker/OT/Group work

MDT for Discharge: Discharge summary to GP/PCT

new & re-referrals discussed and allocated to the most appropriate team member for assessment

urgent referrals seen the previous week are discussed by NCHD’s

CMHT client reviews patient recovery care plans (Centre for MH Care &

Recovery) peer support communication of AOB This helps to: ensure CMHT runs inclusively and cohesively which leads to its effectiveness and increased cooperation encourage sharing of expertise amongst the team ensure good work practices/improves communication feedback to GP’s positive working with administration

The Recovery Care Plan is a collaborative approach between the Service User (SU) and the MDT. This involves self assessment by the SU, and reviews with the treating team

The Recovery Care Plan is also discussed at the MDT. Family and carers are included if consent given by the SU

Weekly reviews by SU and team

Discharge Care Plans – discharge is discussed as soon as is appropriate; written Recovery Discharge Plans are now encouraged (with help of a WRAP approach)

Clinical meetings for joint service users with Rehab Care and National Learning Network

Member of the West Cork Carers Issues Forum (research into Carers needs)

Member of West Cork Mental Health Forum

Management meetings re: Home Focus Team, with NLN

Attend local mental health events

Liaise with Heads of Disciplines and other disciplines

about clinical/management issues/audit.

Performance Indicator stats for CMHT

Member of the local Management Team

Policy reviews with MDT

Clinical caseload of 4-5 clients

Joint assessments/joint home visits with other members of CMHT/urgent home assessments

Point of reference to Home Focus team

Recovery Care Plans for service users in community/

? Recovery Star tool

MDT assessment tool

MDT team meetings serves both community & inpatient service which has advantages and disadvantages

cChallenges

THANK YOU