WEST CORK MENTAL HEALTH SERVICES Team/Care Co-ordination

1. WEST CORK MENTAL HEALTH SERVICESTeam/Care Co-ordination

2. West Cork Catchment Area Bantry, Ctb, Sheep’s HeadHead Skibb/Schull/Mizen Clon/Dway/Ballineen

3. SERVICE DEVELOPMENT AGENDA USER VOICE: RECOVERY AGENDA COMMUNITY DEVELOPMENT AGENDA Mental Health Agenda

4. Moving West Cork Mental Health Servicein a Recovery Direction • 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

5. Moving West Cork Mental Health Servicein a Recovery Direction • ‘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

6. Team Co-ordinator – Process • 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

7. West Cork Mental Health Forum 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

8. Care co-ordination CNS Counselling/ Psychotherapy GP/Primary Care Teams Local Management Business Mtg ANP/Family Therapist in Primary Care/MH Team Co-ordinator SERVICE USER Carer Team working/ cross functional working TEAM WORKING CROSS-FUNCTIONAL WORKING National Learning Network/Rehab Care West Cork Carers Support Group Centre for MH Care and Recovery Employability Home Focus Team Community Mental Health Forum Collaborative Learning DCU Windows

9. Governance of the CMHTTeam Co-ordination 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

10. The administration and triage of referrals in consultation with Consultants and team members • Non-urgent referrals are sent to Team Coordinator / Consultant and discussed/ triaged at team meetings (the single point of entryas 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

11. Liaising with GPs and primary care professionals • 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

12. Referral Pathway 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

13. Chairing sector team meetings/ support team to work in a multi-disciplinary way • 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

14. Recovery Care Plan • 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)

15. Liaising with community agencies & resources (including service user & carer groups) • 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

16. Clinical/management role • 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

17. Challenges c • 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

18. THANK YOU