mental health care pathway (prototype) self-help & caringcaring primary care other agencies...
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Mental Health Care Pathway
(prototype)
Self-help& Caring
Primary care
Other agencies
PsychologicalTherapy Services
(IAPT)
Mental healthservices
Service PathwaysHants Oxon
Care pathways
ME
NTA
L H
EA
LTH
ME
NTA
L HE
ALT
H
iCommissioning
for mental health
General hospital services
Coping with
daily living
problems
Exit fro
m
services
Coping with
daily living
problems
Mental Health Care Pathway
Please insert UK postcode forlocaised information
Mental health Services Children Adults Older people Learning disability Diagnoses Search Help
Web-links that are provided as part of this programme are ones which we hope you will find useful but their inclusion should not imply that the relevant web content is endorsed by NHS South Central or other NHS organisations supporting the development of this programme.
Permission to use pathways developed by South London and Maudsley FT (SLAM) is awaited.
Developed by David Kingdon for NHS South Central with contributions from many individuals for which grateful thanks (comments welcomed to [email protected] )
Comments: [email protected]@southcentral.nhs.uk
Coping withdaily living
problems
Exit from
services
Self-help& Caring for
mental health problems
Primary care Mental health
Other agencies which work with
mental health services
How do I contact Psychological
Therapy Services (IAPT)?
How do I find mental healthServices?
Service pathways through mental health services
Care pathways for mental health
problemsGeneral hospital
Services andMental health
What is a mental health problem?
There is often confusion about what is a mental health problem, mental disorder or mental illness. – A disorder (or problem) could be described as any condition that causes distress or disability
(physical or mental). However whether someone presents, or rarely is presented, for help or requires reduction in their responsibilities e.g. time off work, varies greatly from person to person and in relation to the cause of the disorder.
– Society has standards and mechanisms for deciding whether someone is ill or not – usually relying on the General Practitioner to make that decision.
– For example, depression is a disorder but need not be an illness. It can be very severe, e.g. after a bereavement, but the individual may request very limited support or intervention. On the other hand, relatively ‘mild’ depression may present and treatment may be appropriate in someone with limited coping abilities and little social support. It may be agreed that they are ill and psychological intervention, for example, be reasonable. Similarly for physical conditions, a bruise might be described as a disorder but not an illness – though it could become one if it causes swelling or severe discomfort.
Web-links that are provided as part of this programme are ones which we hope you will find useful but their inclusion should not imply that the relevant web content is endorsed by NHS South Central or other NHS organisations supporting the development of this programme.
Comments:- specific service websites will often have email addresses for comments, if not these can be made to [email protected]
- comments on the website can be made to [email protected]
Developed by David Kingdon ([email protected]) for NHS South Central with contributions from many individuals for which grateful thanks
Getting access to mental health services
• Emergency– Where there is immediate risk to life or serious physical injury, the emergency services should be
contacted using 999.– Examples would be where someone has taken or seriously threatening to take an overdose of
medication or made another suicidal action especially where they are showing signs of its effects, e.g. slurring or sleepiness (ask for ambulance); or where someone is threatening aggression, holding a weapon or committing or about to commit an assault (ask for police).
• Urgent– Where someone is very distressed or may be talking about harming themselves or someone else,
immediate attention may be necessary– If they are currently under the care of mental health services, contact should be made with those
services (local services can be located through NHS Choices ) or their general practitioner or NHS Direct.
– If not under the care of services, contact should be through the person’s general practitioner (or NHS Direct ) or if the person is in a public place (not their own home), the police can be contacted and may intervene.
– A relative of a patient can ask local mental health services for a Mental Health Act assessment by a psychiatrist and approved mental health practitioner
• Routine– Most services accept referrals from General Practitioners and so these referrals usually occur
after discussion about mental health care needs at an appointment with a GP (local services can be located through NHS Choices ).
– Some services accept self-referral (e.g. Psychological Therapy Services , Drugs & Alcohol or Early Intervention in Psychosis teams)
– Some people are referred from the Courts, Prisons or by the Police.
Contact with services
• General hospital– Some people present to Emergency Departments with mental
health problems, e.g. after self-harming or accidents.– They may also present to specialist out-patient clinics or as in-
patients and require treatment, in collaboration with their family doctor and, sometimes, referral to specialist mental health services.
• Criminal Justice Service (Police, Probation, Courts or Prisons)– The police may be called and can act where mental health
issues arise especially where there is concern about harm to others or self in public (and sometimes private) places.
– Courts and prisons may also refer to mental health services including through specialised liaison services.
Primary Care (including general practitioner or family doctor services)
• GPs provide front-line mental health care as part of their service to their patients.
• Most people with mental health problems will therefore never require help from specialist mental health or psychological treatment services.
• However where it is necessary, such referrals are possible.
Quality & Outcomes Framework
Primary Care
ASSESSMENT EPISODECOMPLETIONINTERVENTION
NO ACTION
REFERRAL
Explanation of symptoms or sign-posting may be sufficient. Consider watchful waiting for
emotional difficulties.
Holistic assessment including both mental and physical state.Consider carer perspective
Consider diagnosis especially early intervention in psychosis
Watchful waiting & self-help resourcesWhere appropriate, agree shared care with
mental health services – especially where non-cooperation is issue.
Medication or brief psychological intervention – see care pathways &/or:
Resource: The management of patients with physical and psychological problems in primary care: a practical guide
Access local psychological therapy services (IAPT) or
mental health servicesIf referral refused by patient,
consider discussion with local CMHT or
early intervention team
Consider relapse prevention and sign-posting
Underpinning values10 Essential Shared Capabilities.• Working in Partnership.• Respecting Diversity.• Practising Ethically.• Challenging Inequality.• Promoting Recovery.• Identifying People’s Needs and Strengths.• Providing Service User Centred Care.• Making a Difference.• Promoting Safety and Positive Risk Management.• Personal Development and Learning.
Partner Agencies
Statutory:• Police
– Hampshire– Thames Valley
• Councils– Hampshire– Oxfordshire– Southampton
• General Hospitals– Hampshire
• Southampton University Hospital Trust• Royal Hampshire County Hospital
• Basingstoke Hospital
– Oxfordshire• Radcliffe
Voluntary:• National
– AgeUK– Alcohol Concern – Alzheimers society– Centre for Mental Health – MENCAP– Mental Health Foundation– MIND– RETHINK – Voluntary Services– YOUNG MINDS
• Local– MIND (Oxon Solent)– Restore (Oxon) – No Limits (Soton)– Voluntary Services (Oxon Soton)
• Housing & Employment– City limits (Soton)– Shelter
For further help:Mental Health
Care Pathways
Pat
ient
rat
ed o
utco
me
mea
sure P
atient rated outcome m
easureAssistance with coping
with life’s problems
Leisure activities
Work
Caringfor others Relationships
Memory problems
Physical health
Money
Mental distress
Spiritualissues
General practicaladviceCultural
support Education
Housingissues
Drugs &Alcohol
DropBy
Housing issues
• National organisations– Shelter– Crisis– Homeless Link
• Gateways to homelessness services:– Homeless Healthcare Services (Soton)– Street Homeless Prevention Team (Soton)
• ‘No-One Left Out: Communities Ending Rough Sleeping’• Mental health and homelessness good practice guide • Asylum seekers
GENERAL HOSPITALSERVICES
• Ambulance Services• Emergency Department
– Access to mental health services– Management of Deliberate Self-Harm
• Perinatal (mother & baby) mental health care• Psychological medicine (General hospital liaison)
• Mental Health Act , Mental Capacity & Deprivation of liberty (DOLS) guidance
• Specific conditions– Dementia & Delirium– Physically unexplained symptoms– Other mental health conditions
Local Hospitals
Care pathways
• These are ways of describing the care needed for specific mental health conditions.
• Broadly these are:– Emotional difficulties, usually presenting with distress– Psychosis, where there is some confusion or disagreement with
others about what is really happening– Memory difficulties, where these may be from changes to the
brain– Developmental difficulties where development has been held
back in learning disability or is a problem, e.g. with behaviour– Substance misuse - drug or alcohol problems
• Much fuller information is given in books & leaflets or diagnostic systems.
Care pathwaysG
loba
l out
com
e m
easu
reP
atie
nt r
ated
out
com
e m
easu
re
Global outcom
e measure
Patient rated outcom
e measur
e
Payment-by-Results
R&D – studies actively recruiting
Emotional difficulties
Substance misuse
Developmental difficulties
Memory Difficulties
R&D
Psychosis R&D OASIS
Self-diagnosis
Values
Care pathwaysG
loba
l out
com
e m
easu
reP
atie
nt r
ated
out
com
e m
easu
re
Global outcom
e measure
Patient rated outcom
e measur
e
Payment-by-ResultsiR&D – studies actively recruiting
Emotional difficulties
Substance misuse
Developmental difficulties
Memory difficulties
R&D
Psychosis R&D OASIS
Anxiety/depression& related conditions
‘Rapid cycling’ Borderline Personality
Disorder
Bipolar disorder R&D OASIS
Eating disorders
Alcohol Drugs
Other: Incl. Autism (ASD),
ADHD, Conduct disorder.
Learning disability
Values
Anxiety/depression
etcpathway
NICE guideline
NICE guideline
Anxiety
Depression
Anxiety/depression, etc
(diagnosis)
Spe
cific
out
com
e m
easu
res
Specific outcom
e measures
Care Pathways – Anxiety/depression & related conditions
Somatising‘physically
unexplained’
IAPT Guidance
OCD & Body Dysmorphic
Disorder’
PTSD
NICE guideline
NICE guideline
ReviewNICE
priorities
ReviewNICE
priorities
ReviewNICE
priorities
ReviewNICE
priorities
Self-help & caring
Confirm diagnosis
Communitypathway
Not require Mental Health
Serviceintervention
Requires Mental Health
Serviceintervention
Medicationreview
Psychol-ogicalreview
Specialistmood
disorderservice
Acutecare
pathway
Exit from
services
NICE guidelineS
Assessment& risk
management
Care Pathway – Anxiety/Depression& related conditions
PbR clusters
Spe
cific
out
com
e m
easu
re (C
OR
E &
IA
PT
) S
pecific outcome m
easure
ReviewNICE
priorities
Requiresmaintenance
support
Assertiveoutreach/Recovery
team
CMHT
Referral toPsychological
Therapy Services (IAPT)
Asylum seekers
Self-help & caring
Service pathways Adult services
Child & AdolescentServices
Older people’sservices
Substance misuse services
Glo
bal o
utco
me
mea
sure
s P
atie
nt r
ated
out
com
e m
easu
re
Global outcom
e measures
Patient rated outcom
e measur
eSERVICE PATHWAYS
Transitional protocol
Transitional protocol
Transitional protocols
Learning disabilityservices
Forensic services
Finance Training HR
Hampshire
Information
(electronic record)
Perinatal
CommunityAcute care
Liaison
Recovery
Memory assessment
CommunityAcute care
Liaison
Early Intervention
QUALITY Essentials
CQUIN
Standards
& Survey
National Patient Safety Agency
Values
Perinatal
CommunityAcute care
Adult services
Child & AdolescentServices
Older people’sservices
Substance misuse services
Global outcom
e measures
Patient rated outcom
e measur
e
MENTAL HEALTH SERVICE PATHWAYS
Transitional protocol
Transitional protocol
Transitional protocols
Learning disabilityservices
Forensic services
Training
Liaison
Recovery
Service pathways
Glo
bal o
utco
me
mea
sure
s P
atie
nt r
ated
out
com
e m
easu
re
Information
(electronic record)
Memory assessment
CommunityAcute care
Liaison
QUALITY Essentials
CQUIN
Standards
& Survey
National Patient Safety Agency
Values
Perinatal
CommunityAcute care
Adult services
Child & AdolescentServices
Older people’sservices
Substance misuse services
Global outcom
e measures
Patient rated outcom
e measur
e
MENTAL HEALTH SERVICE PATHWAYS
Transitional protocol
Learning disabilityservices
Forensic services
Training
Liaison
Recovery
Service pathways
Glo
bal o
utco
me
mea
sure
s P
atie
nt r
ated
out
com
e m
easu
re
Information
(electronic record)
Memory assessment
CommunityAcute care
Liaison
QUALITY Essentials
CQUIN
Standards
& Survey
National Patient Safety Agency
Values
Policies
Mental health
pathway
Memory assessment
pathway
Early Memory Difficulties
MemoryDifficultiesR&D
(diagnosis)
Glo
bal o
utco
me
mea
sure
– H
oNO
S
65+G
lobal outcome m
easure – HoN
OS
65+
Care Pathways – Memory Difficulties
Moderate need pathway
High physical or engagement need pathway
High need pathway
Reviewpriorities
Reviewpriorities
Reviewpriorities
Reviewpriorities
Reviewpriorities
Self-help & caring
Quality & Outcomes Framework
(mental health)
Resources
RCGP forum
Early intervention in psychosis
Check your local surgery results
DIALOG
How satisfied are you with your mental health?How satisfied are you with your physical health?How satisfied are you with your job situation?How satisfied are you with your accommodation?How satisfied are you with your leisure activities?How satisfied are you with your friendships?How satisfied are you with your partner/family?How satisfied are you with your personal safety?How satisfied are you with your medication?How satisfied are you with the practical help you receive?How satisfied are you with consultations with mental health professionals?
1. Couldn’t be worse2. Displeased3. Mostly dissatisfied4. Mixed 5. Mostly satisfied6. Pleased7. Couldn’t be better8. No response
Additional help required? Yes/No…………………………………….
Recovery Star
Self-helpGENERAL
INFOBooks
NHS ChoicesMIND
MENCAPRETHINK
Choice and MedicationRoyal College of
Psychiatrists
SUBSTANCE MISUSEBooks
Talk-to-Frank (drugs) Drinkaware
Alcoholics AnonymousAlcohol Concern
NHS ChoicesRoyal College of
Psychiatrists
PSYCHOSISBooks
Hearing Voices NetworkRETHINK
MINDNHS Choices
Royal College of Psychiatrists
MEMORY DIFFICULTIES
BooksDementia gateway
NHS ChoicesRoyal College of
Psychiatrists
EMOTIONAL DIFFICULTIES
BooksNHS Choices
Computerised CBTRoyal College of
Psychiatrists
Carers
BooksAl-Anon (alcohol carers support)
Alcohol ConcernCaring (finance, etc)
Care choicesChoice and Medication
Confidentiality and sharing informationDementia gateway
Mental health care (psychosis)Mental health first aid
NHS Carers DirectPrincess Royal Trust for Carers
RETHINKRoyal College of Psychiatrists
Emotional difficulties Psychosis
Memory difficulties
Developmentaldifficulties
Substance misuse
Acute care pathway
REFERRALINITIATING
CARETREATMENT DISCHARGE
CRHT
INPATIENT
PICU
Acute PathwayQuality & Performance
Dashboard
Acute care pathway
REFERRALSingle point of access & rapid response
by Crisis Resolution Home Treatment Team (CRHT)
Assessment involving SU, carer and relevant others (risk issues including
safeguarding children and adults)Consider Mental Health Act , Capacity &
Deprivation of liberty (DOLS)Assess at home whenever possible
REFERRAL OUTCOME Admission to hospital
CRHT care Refer to CMHT or maintenance by
current team Engage other services/signpost
Discharge to GP
PICU Inpatient CRHT
BUILD ON INITIAL ASSESSMENT (INCLUDING
RISK) AND BEGIN RECOVERY AND
STRENGTHS FOCUSSED
THERAPEUTIC APPROACH WITH SERVICE USER INVOLVEMENT
Acute care pathway
INITIATING CARE
Communicate with referrer, home acute unit & GPAssertive Engagement
Gate KeepingEngage Carer /carer support worker
Maintain contact with care co-ordinators (community pathway)Obtain case notes or electronic equivalent
Confirm admission objectivesCommence discharge planning with projected discharge date,
housing needs & care PlanHoNOS on admission
Consider input required from social, advocacy and other agenciesComplete admission checklist
‘Meet and Greet’ establish consent to admissionImmediate risk assessment/support level/ward environment
Orientation to wardIdentify physical needs (e.g. check Body mass index [BMI])
If detained read rights
Acute care pathway
TREATMENTAssertive engagement, intensive
supportTime limited intervention,
medication review if needed.Manage self-harm & hostility (include incident & complaint
reporting)Practical help with basics of daily
living and crisis plan Use of Crisis beds when availableEngage Carer/care support worker
Maintain contact with care coordinator (community pathway)
InvestigationsFormulate problems/diagnosis on
bio-psycho-social modelConsider medication and other
interventions including ECT
Side effect monitoring, improve concordance & Wellness Recovery
Action Plan (WRAP)Supplement assessment which may
include the intervention of other professionals, e.g. forensic
Commence interventions to include psychological in broad sense (include
CBT, interventions to enhance resilience, crisis planning,
relapse prevention, problem-solving, anxiety management)Regular MDT review
Consider input required from social care, advocacy and other agencies
Senior/Professionals’ reviewWard round/Consultant review
Consider involvement of & early discharge to CRHT
Manage physical health care needs
Acute care pathway
DISCHARGEEngage Carer/care support worker
Agree discharge datePrepare for discharge/transfer
Consider active involvement of CRHT & input required from social care, work and other
agenciesCPA joint review with care
coordinator/community consultant including relapse prevention plan
Use of step-down/Crisis beds when availableConsider trial leave
Complete discharge checklistHoNOS on discharge
Agree follow-up: Outpatient, CRHT & Care Co-ordinator (<48hr [high suicide risk] or <7-day)
Discharge summary (within 2 weeks)
Community pathway
REFERRALINITIATING
CARETREATMENT DISCHARGE
CMHT
Community PathwayQuality & Performance
Dashboard
Community pathway
REFERRALProvide single point of access
Rapid response proportional to urgencyAssessment involving patient, carer and
relevant others (also risk issues including safeguarding children and
adults)REFERRAL OUTCOMES
Brief intervention (include Discharge Liaison Team involvement).
Enter acute care pathwayRefer to specialist team (Early Intervention,
Substance Use, Assertive, Rehabilitation) Accept referral & allocate care co-ordinator
&/or to outpatient care; engage other services/signpost
Discharge to GP
CMHT
BUILD ON INITIAL ASSESSMENT (INCLUDING
RISK) HoNOS AT INITIAL
CONTACT.BEGIN
RECOVERY AND STRENGTHS FOCUSSED
THERAPEUTIC APPROACH WITH SERVICE USER INVOLVEMENT
Community Pathway
INITIATING CARE
Arrange appointmentAssertive Engagement
Engage Carer /carer support workerDevelop treatment objectives & timescale
Commence Care PlanningConsider input required from social care, work, advocacy,
housing and other care agenciesIdentify physical needs (e.g. check Body mass index [BMI])
Consider need for psychiatric reviewMental Health Act (on Section 17 leave, 37(41) or
Community Treatment Order)Consider self-directed support (personalisation) & Wellness
Recovery Action Plan (WRAP)Communicate with referrer & GP
Community pathway
TREATMENT
Formulate problems/diagnosis on bio-psycho-social modelTime limited intervention,
medication review if needed.Practical help with basics of daily
living and crisis planConsider need for psychiatric
review & review medication needsConsider fitness to drive or use
machinerySupplement assessment which may include the intervention of
other professionals, e.g. psychologist, occupational
therapistReconsider self-directed support
(personalisation)
Commence interventions to include psychological in broad sense
(include CBT, DBT, interventions to include resilience, crisis planning,
relapse prevention, problem solving, stress management)
CPA review (repeat HoNOS)Report & manage any complaints Consider input required from social
care, work and other agenciesPhysical needs reassessment Continue to assess risk, MHA
& need for acute pathwaySide-effect monitoring, improve
concordanceCaseload & clinical supervision
Review NICE guideline for conditionRegular communication with GP,
accommodation provider & carer
Community pathway
DISCHARGE/TRANSFER
Consider whether criteria for recovery pathway met
Engage Carer/carer support workerConsider input required from social care and
other agenciesAgree discharge date
Prepare for discharge/transferCPA review with relapse prevention plan
HoNOS on dischargeCommunicate with GP
OPMH Community pathway
REFERRALINITIATING
CARETREATMENT DISCHARGE
CMHT
Community PathwayQuality & Performance
DashboardDropBy
OPMH Community pathwayAssessment
REFERRALProvide single point of access
Rapid response proportional to urgencyAssessment involving patient, carer and
relevant others (also risk issue including safeguarding children ,adults)
RISK ASSESSMENT, HoNOS
REFERRAL OUTCOMES• Brief intervention (include Liaison Team
involvement).• Accept referral & allocate care co-
ordinator• Engage other services/signpost • Enter inpatient pathway • Discharge to GP
CMHT
Multidisciplinary review.
Initiate other assessments- psychology, occupational
therapy, nursing ,medicalReview of Risk.
Initiate care planning.
Liaise with partner organisations- Adult Services,
Community Healthcare.
OPMH Community Pathway
INITIATING CARE
Arrange appointment, either at home or community baseEngage Carer /carer support worker
Identify further assessments needed- psychological, cognitive assessment, occupational therapy, physical
health assessment.Consider need for psychiatric review including
Mental Health Act assessment .Identify need for investigations, blood test or scanning.
Consider referral to Adult Services, care agencies, advocacy, work
Develop treatment objectives & timescaleCommence Care Planning
Consider self-directed support (personalisation)
Communicate with referrer & GP
OPMH Community pathway
TREATMENT•Formulate problems/diagnosis.•Identify interventions and time frame. (Care Planning)•Practical help with basics of daily living and crisis plan•Consider psychiatric review & review medication •Consider fitness to drive or use machinery•Reconsider self-directed support (personalisation)•Psychological interventions including cognitive work, CBT, crisis planning, relapse prevention, problem solving, stress management
• Occupational interventions to support independent living
• Consider input required from adult services, work and other agencies
• CPA review (repeat HoNOS)• Physical needs reassessment • Ongoing Risk Assessment• Consider MHA & need for
acute pathway• Side effect monitoring, improve
concordance• Caseload & clinical supervision
Report & manage any complaints • Review NICE guideline for
condition• Regular communication with GP,
accommodation provider & carer
DISCHARGE/TRANSFER
Consider whether criteria for discharge are metEngage Carer/carer support worker
Consider input required from Adult Services and other agencies
Agree discharge datePrepare for discharge/transfer
CPA review with relapse prevention planHoNOS on dischargeCommunicate with GP
OPMH Community pathway
Eating Disorder Service Pathway
REFERRAL Waiting list INTERVENTIONS REVIEWNICE
PRIORITIES
DISCHARGE
REFERRALScreening: Assess comorbidities jointly with CMHT
Inform referrerComprehensive Assessment involving service user, carer and relevant others (include mental health, social functioning & risk issues - including physical); relevant measures.
Consider Mental Health Act & Deprivation of liberty (DOLS)Team discussion; choose treatment options; discuss & agree with service user
REFERRAL OUTCOMETaken onto waiting list by Eating disorder serviceRefer to CMHT or maintenance by current team
Engage other services/signpost Discharge to GP
INTERVENTIONSOutpatient, day care (12 weeks) or Inpatient (Acute Care Pathway or General
Hospital)1st session measures:
CPA reviewPhysical monitor with relevant investigations (coordinated with GP)
Guided self-help: 4 month – 6 direct contactsNutritional advice
Group workMedication review
Psychological interventions: Family therapy, Group work, DBT modified, individual & group; Inter-personal therapy – 24 sessions: CBT – 20 sessions
CAT – 16, 24, or 32 sessions: Measure CORE-10
DISCHARGEEngage Carer/care support worker
Agree discharge datePrepare for discharge/transfer
Consider active involvement of CRHT & input required from social care, work and other agencies
CPA joint review with care coordinator/community consultant including relapse prevention plan
HoNOS on dischargeAgree follow-up: Outpatient, CRHT & Care Co-ordinator
Discharge summary (within 2 weeks)
REFERRAL
Urgent
ACUTE CARE
PATHWAY
Refer on to CMHT or other mental health service or back to GP
or referrer
REFERRAL OUTCOME
TAKEN ON BYEIT
(up to 36 months)
Early Intervention in Psychosis Service Pathway
Non-Urgent(within 7 days)
EIPASSESSMENT
First presentation for assessment of
psychosis (aged 14-35)
24 hour access
NO PSYCHOSISNO PSYCHOSIS
ASSESSMENT BY EIT
(up to 6 months)
Provide service & self-help materialsComplete specific outcome measures: PANSS, GAF, HADS, Drake.Follow COMMUNITY & PSYCHOSIS
PATHWAYSFocus on psychological and
family work.Carer support
Assertive care coordinationMedication management
Early intervention
Sites [IRIS, EPPIC]
General Hospital Liaison Service Pathway
REFERRALPROCESS(in-patient & outpatient)
REFERRAL ROUTE
REFERRAL CRITERIA
TEAMRESPONSE
REFERRALS FROM WARDS AND THE EMERGENCY DEPARTMENT
Accepted from medical staff responsible for the patient between: 09:00 –
17:00hrs, Monday to Friday for 18 – 65 year olds
If the referral is received after 16:00:-There will be provision of initial advice
and assessment if there is a clinical crisis
Referrals from the Emergency Department to the Home Treatment Service if the patient is expected to
become medically fit for discharge later in the evening
Assess in working hours if there is no need for urgent specialist mental health input. Advice will be provided to General
Hospital staff to guide management if the patient deteriorates
REFERRAL CRITERIAAll patients admitted after self harm (overdose, self laceration, attempted hanging, jumping
from a height, gunshot wound): Organic psychosis: Schizophrenia and other functional psychosis where the disorder is affecting management in General Hospital: Depression or
anxiety interfering with physical healthcare or recovery: Adjustment reactions interfering with physical healthcare or recovery: Eating disorders leading to admission: Behavioural
disturbance if mental health issues are thought relevant: Somatoform, dissociative and fictitious disorders if there is frequent attendance or co-morbid physical disease requiring ongoing in-patient or out-patient care from General Hospital: Diagnostic dilemmas where mental disorder is a possibility: Patients where psychological factors are thought to be
affecting communication or other aspects of care by General Hospital staff: Capacity advice if mental health issues are thought relevant or the decision is complex and the General Hospital
consultant wants further advice after their own assessment: Alcohol and other substance misuse if other mental health problems are present (e.g. severe depression remaining after
detoxification, hallucinations remaining after detoxification)The following types of problems should not be referred but be highlighted to the GP for management after discharge: Mild depression or anxiety: Pre-existing mental illness not
affecting care in General Hospital: Alcohol and other substance misuse
REFERRALS OUTSIDE THE WORKING HOURS OF THE TEAM
Only patients requiring crisis/urgent clinical advice or assessment by a mental health specialist after initial
assessment and attempts at management by the responsible medical team will be accepted outside working
hours. It is expected that the referral will be made by a doctor of at least middle grade seniority. Referrals from General Hospital wards:
The referring doctor should contact the the duty psychiatric service (nurse bleep holder in Antelope House
(bleep 1504)). The call will be passed to the senior psychiatrist on call who will provide telephone advice and,
if necessary, come to see the patient. Referrals from the Emergency Department:
The referring doctor should contact the Crisis Resolution/Home Treatment Service
Crisis referrals from General Hospital out-patient clinics or occupational health
Mental health assessment should be arranged by the patient’s GP or rarely Emergency Department, who can
then access community mental health resources if required.
REFERRALS TO PSYCHOLOGICAL MEDICINE OUT-PATIENT CLINICReferrals for routine out-patient assessment can be accepted for patients aged 18-65 years requiring ongoing out-patient or in-patient follow up
from General Hospital.Referrals to the out-patient clinic should be made by letter from the Consultant (or Specialty trainee after discussion with the consultant)
responsible for the patient detailing reasons for referral and summary of physical health issues. It is helpful to attach recent clinic letters (the service does not have access to eDOCs).
If the referral cannot be seen due to another service being thought more appropriate or lack of capacity in the service then this decision will be communicated by letter to the referrer and GP. Patients requiring urgent out-patient assessment (for example due to active suicidal ideas or acute
psychotic symptoms) cannot be seen by the service. This initial mental health assessment needs to be undertaken by the GP.Advice for General Hospital staff regarding patients already receiving treatment from another mental health should be sought from that mental
health team. If it is thought that a specialist assessment from the Psychological Medicine team would be helpful due to the complexity of interaction between physical and mental health issues then the specific reasons for referral to the service and the details of the existing mental
health team need to be included in the referral letter. The letter should also be copied to the community mental health team. The following problems are suitable for referral: Prolonged or severe adjustment disorder impairing physical, occupational or social functioning;
Moderate depression or anxiety disorder impairing functioning or self care of the physical health condition; Somatoform and dissociative disorders resulting in frequent admissions or attendance to the Emergency Department or out-patients; Psychological issues impacting on self
care e.g. poor adherence; Psychological problems affecting physical health or health care utilisation where the patient does not yet accept referral to psychological therapy services but agrees to attend the Psychological Medicine clinic.
The following problems should be managed via the GP (who may refer to community mental health services); Urgent referrals – e.g. strong suicidal ideas, active psychosis; Mental health problems in patients who will not be receiving ongoing care from General Hospital; Mild depression or
anxiety; Depression or anxiety disorders unrelated to the physical health condition; Substance misuse; Somatoform or other medically unexplained symptoms not resulting in frequent presentation to General Hospital
General Hospital Liaison Service Pathway
REFERRALPROCESS
REFERRAL ROUTE
REFERRAL CRITERIA
MENTAL HEALTHINTERVENTION
TEAM RESPONSE TO REFERRALSOn receipt of referral admin staff will check if the patient is already known to local mental
health services, obtain any recent mental health correspondence and notify clinical staff of the referral.
If the clinician receiving a referral requires more clinical information to prioritise response then they will contact the referrer or other mental health teams as required. If the patient will not be seen the same day then a clinician will telephone the referrer to check that the patient
is settled and, if appropriate, give advice regarding how to contact out of hours services should the clinical situation deteriorate. If the referrer is unavailable then the clinician will
liaise with ward nursing staff.If referrers telephone the team for advice or to discuss a referral admin staff are expected to take down the following information: Name of patient; Hospital and NHS numbers; Age; Name of the referrer and bleep or other contact number; Ward location; Is it an acute crisis
needing immediate discussion with a practitioner?Supervision policy.
TRANSFER TO GENERAL HOSPITAL FROM A MENTAL HEALTH IN-PATIENT UNIT
HPFT Clinical Policy 57 & SUHT details expectations and responsibilities for HPFT and General Hospital staff for patients transferred to General Hospital for physical healthcare from a
mental health in-patient unit. If a patient needs constant (1:1) observation due to their
mental health needs in General Hospital then the responsibility for providing this is local mental health trust if the patient was transferred from a MHT bed. Responsibility lies with General Hospital if the patient was admitted from the community or
another acute hospital.Mental health act issues.
COMMUNICATION AND DOCUMENTATIONTeam members have a responsibility to follow team practices
regarding documentation.Document the clinical assessment, risk assessment, formulation, and management plan in the General Hospital notes and retain a photocopy for DPM notes; Discuss with DPM team as necessary; Recording of risk and clinical assessment has to be accurate; Ask patient to complete consent form to receive a copy of correspondence to GP; Complete the checking of information, ethnicity and accommodation forms; Ensure admin staff have recorded the
referral on the daily referral log sheet; Complete contact record for computerised notes (RiO) which admin staff then enter; Brief letter to the GP faxed on the day of assessment for
self harm; Full assessment letter at time of discharge from the team for patients seen for reasons other than self harm; Complete audit assessment form post discharge (Appendix
6); Dictate letter to the referrer, GP, patient and other professionals involved in the patient’s care after all initial and final out-patient appointments. Letters should also be sent after each appointment with medical staff and at intervals or if significant new information arises during
intensive psychosocial interventions undertaken by practitioners.
REFERRAL ROUTEReferrals should be made by faxed referral form with letter (unless assessment after admission for self harm) which
should always include:-reason for referral / question asked of the Psychological Medicine team; mental state assessment and other reasons leading to suspicion of mental illness or psychological problems impairing
management within General Hospital: reason for treatment in General Hospital: a summary of physical management and past admissions: results of recent investigations
If it is unclear whether a patient needs to be referred, or the referrer wants to discuss the referral for other reasons, then they should telephone the department. If there is no clinician present in the team base at the time, admin staff
will record the name and contact details of the referrer and arrange for a clinician to ring back. In crisis situations, the referral can be made solely by telephone discussion with a clinician in the team
Prioritisation of referrals: Initially on the basis of clinical urgency and risk and secondly on location in General Hospital in order: Emergency Department, Acute Medical Unit, other wards.
The team aims to respond within the following time frame: Crisis: 1 hour (usually within 30 minutes): Urgent: same day (if the referral is received late in the day then response is likely to be by telephone advice that day and direct
assessment the next day): Routine: 3 days (usually within 1 working day)
USE OF THE MENTAL HEALTH ACT IN THE GENERAL HOSPITAL
• If a patient is transferred from a mental health in-patient unit whilst detained under the Mental Health Act (MHA), responsibility remains with the mental health trust if the patient has been transferred under section 17 leave. The doctor responsible for the patient’s mental health care (Responsible Clinician as defined by the MHA) remains the Consultant Psychiatrist, or other professional if they are the RC, in the mental health unit. DPM clinical staff will liaise with the in-patient unit regarding mental health assessment and will complete a weekly summary to fax to the mental health unit for discussion of the patient in ward rounds.
• If a patient is detained under the MHA whilst in General Hospital, then General Hospital has legal responsibility for mental health care. They will therefore have responsibility for arranging tribunals etc.
• The section papers need to be formally received by the site co-ordinator in SGH for the section to be valid.• Section 5(2) is a doctor’s holding power and can be applied by any fully registered medical practitioner (not FY1
doctor) to detain any admitted patient (not anyone in the Emergency Department) who the doctor suspects of having a mental illness necessitating detention under a more prolonged section of the MHA. When the section is placed, the site co-ordinator should be involved and they should notify the Approved Mental Health Practitioners (AMHPs) in Southampton Home Treatment Service so that a full MHA assessment can be arranged. The section 5(2) lasts up to 72 hours.
• Sections 2 and 3 of the MHA enable detention for 28 days for assessment or 6 months for treatment of a mental disorder. They only provide legal power to treat physical problems if these are a direct cause or consequence of the mental disorder.
• The site co-ordinators will fax a notification of sectioning using section 2 or 3 of the MHA to the Department of Psychological Medicine the next working day. The Liaison Psychiatrist (LP - Dr Butler) will take on the MHA role of Responsible Clinician for adults aged 18-65 years. For older adults a clinician in DPM needs to speak to the relevant OPMH Consultant to take on the Responsible Clinician role. For leave periods, LP (Dr Butler) will have notified the team of the Consultant Psychiatrist covering the Responsible Clinician role.
• For section 2 or 3, only the Responsible Clinician (LP or other nominated Consultant Psychiatrist) can allow leave from General Hospital grounds (which needs a section 17 leave form completing) or discharge of the section.
• As for other patients, clinicians in DPM have a responsibility to advise General Hospital on levels of observation, psychiatric treatment and other management of the mental health problems for patients detained under the MHA in General Hospital.
OPMH Medication Management• Depression treatment guidelines for Older Adults• Antidementia drug treatment guidelines• Guidelines for Rapid Tranquilisation for Older Adults• Prescribing Lithium• Oral Antipsychotics• Prescribing guidelines for treatment of behavioural problems in Dementia• DVLA Guidelines on fitness to drive• Choice and Medication (UK Psychiatric Pharmacists Information site)
• Medicines Control, Administration and Prescribing Policy• Antibiotic Prescribing Guidelines • Cholesterol Guidelines • Clozapine initiation – inpatient & community • Prescribing guidelines for BPD (under development)• Risperdal Consta forms &monitoring guidance for clients receiving treatment for psyc
hosis
ECT
OPMH Community intervention• Health Care Support worker
– Engagement– Social intervention– Documentation
• Social Worker– Social needs Assessment – Care Planning– Care Coordination– Care Management– Liaison
• Community mental Health Nurse– Assessment– Care Planning– Care Coordination– Intervention– Liaison
• Nursing and Residential Home Liaison
– Assessment– Care Planning– Care Coordination– Intervention– Liaison
• Acute Hospital Liaison– Assessment– Care Planning– Intervention– Liaison
• Memory Nurse– Assessment– Care Planning– Care Coordination– Intervention– Liaison
• Day Therapy Nurse– Assessment– Care Planning– Care Coordination– Intervention, individual and group– Liaison
• Psychiatrist – Psychiatric assessment– Risk management– Diagnosis – Medication management– Care coordination
• Psychologist– Psychological assessment– Cognitive Assessment– Care Coordination– Psychological intervention– Psychological formulation, training & supervision
• Occupational therapist– Assessment– Occupational Assessment including AMPS– Care Planning– Care Coordination– Intervention– Liaison
Confirm diagnosis
Prominentpsychoticsymptoms
Problem-solving
guidance
Communitypathway
Not require Mental Health
Serviceintervention
Requires Mental Health
Serviceintervention
Medicationreview
Psychol-ogicalreview
Specialistservice
Acutecare
pathway
Exit from
services
NICE guideline CG78
Psychosispathway
Assessment& risk
management
Review
Care Pathway – Emotional difficulties(‘borderline personality disorder’)
PbR cluster
Spe
cific
out
com
e m
easu
re (C
OR
E)
Specific outcom
e measur
e
ReviewNICE
priorities
Requiresmaintenance
support
Assertiveoutreach/Recovery
team
CMHT
Self-help & caring
Emergence
Consider diagnosis
Co-existing substance
misuse
Communitypathway
Not require Mental Health
Serviceintervention
Requires Mental Health
Serviceintervention
Medicationreview
Psychosocialreview
ReviewNICE
priorities
Acutecare
pathway
Requiresmaintenance
support
Assertiveoutreach/Recovery
team
CMHT
Exit from
services
NICE guideline CG82(for co-existing drug misuse – awaited)
Substancemisuse pathway
Assessment& risk
management
Care Pathway – Psychosis
PbR clusters
Spe
cific
out
com
e m
easu
res
(Po
sitiv
e &
Ne
ga
tive
sym
pto
ms)
Specific outcom
e measur
e
Earlyintervention
Co-existing ‘borderline p.d.’
‘Emotionaldifficulties’ pathway
Self-help & caring
Consider diagnosis
Co-existing substance
misuse
Communitypathway
Not require Mental Health
Serviceintervention
Requires Mental Health
Serviceintervention
Medicationreview
Psychosocialreview
ReviewNICE
priorities
Acutecare
pathway
Requiresmaintenance
support
Assertiveoutreach/Recovery
team
CMHT
Exit from
services
NICE guideline CG38
Substancemisusepathway
Assessment& risk
management
Care Pathway – Bipolar Disorder
PbR clusters
Spe
cific
out
com
e m
easu
res
(Ma
nia
& D
ep
ress
ion
)S
pecific outcome
measures
Earlyintervention
Perinatalperiod
Self-help & caring
Consider diagnosis
Communitypathway
Not require Mental Health
Serviceintervention
Requires Mental Health
Serviceintervention
Precription and
review of medication
MemoryMatters
ReviewMemory
AssessmentServiceCriteria
MemoryAssessment
Service
Requiresmaintenance
support
MemoryClinic
CMHT
Exit from
services
NICE guideline CG42
Assessment& risk
management
Care Pathway – Early Memory Difficulties
PbR cluster 18
Spe
cific
out
com
e m
easu
re -
HoN
OS
65+
Specific outcom
e measures – H
oNO
S 65+
Psychologicaland
carers support
Review
DementiaAffecting
IndependentLiving
Pathway
DementiaAffecting
IndependentLiving
Self-help & caring
Care Pathway – Memory Assessment Service (Cognitive impairment -Low need)
Clinical assessment
Care Pathway Criteria & Risk
assessment
Memory problems affecting
Independent living
Memory problems not affecting
Independent livingExit form services
Spe
cific
out
com
e m
easu
re H
oNO
S 6
5+S
pecific outcome m
easure HoN
OS
65+
Psychological support
Prescription and
monitoring of medication
Carer Support
Review Care Pathway
Criteria
Community Pathway(Moderate need)
NICE guideline for Dementia – CG 42
PbR Cluster 18
Memory Problems not requiring Mental Health service
intervention
Multi-Professional Care Planning
Memory Matters
Self-help & caring
Care Pathway – Complicated cognitive impairment or Dementia (Moderate Need)
Clinical assessment
Care Pathway Criteria & Risk
Assessment
Memory problems affecting
Independent living
Memory problems not affecting
Independent living
High ormoderatelevel of need?
Multi-Professional
Care Planning
Exit form services
Spe
cific
out
com
e m
easu
re H
oNO
S 6
5+S
pecific outcome m
easure HoN
OS
65+
Psychological and
occupational therapy
interventions
Prescription and
monitoring of medication
Carer Support
Review Care Pathway
Criteria
Complicated Dementia with high level of need Pathway
Joint working with partner
organisations
NICE guideline for Dementia – CG 42
PbR Cluster 19
High
Moderate
Memory assessment service pathway
Additional care provided
at home
Self-help & caring
Care Pathway – Complicated cognitive impairment
or Dementia (High Need)
Clinical & social care
assessment
Care Pathway Criteria & Risk
Assessment
Memory problems affecting Independent living (high need)
Memory problems affecting
Independent living (moderate need)
High level of physical Need/
engagement?
Multi-Professional
care planning
Exit form services
Spe
cific
out
com
e m
easu
re H
oNO
S 6
5+S
pecific outcome m
easure HoN
OS
65+
Psychological/therapeutic Interventions
Prescription and
monitoring of medication
Carer Support
Review Care Pathway
Criteria
Complicated Dementia with high level of physical need/Engagement Pathway
Additional care provided
at home
NICE guideline for Dementia – CG 42
PbR Cluster 20
Yes
no
Community Pathway(Moderate need)
Psychiatric inpatient
assessment
Acute hospital treatment
Adult Services respite
Continuing Health Care
Assessment
Self-help & caring
PbR Cluster 21 Care Pathway – Cognitive Impairment or Dementia (High Physical Need/Engagement)
Clinical & social care
assessment
Care Pathway Criteria & Risk
Assessment
Memory problems affecting Independent living (High Physical need/Engagement)
Memory problems affecting
Independent living (High need)
Multi-Professional care planning
Exit form services
Spe
cific
out
com
e m
easu
re H
oNO
S 6
5+S
pecific outcome m
easure HoN
OS
65+
Psychological/therapeutic Interventions
Medication for behaviour that challenges
Carer Support
Review Care Pathway
Criteria
Intensive home care support
NICE guideline for Dementia – CG 42
Complicated Dementia with high level of need Pathway
Psychiatric inpatient assessment
Acute hospital treatment
Nursing or Residential home placement
Continuing Health Care
Assessment
End of Life Care Pathway
Self-help & caring
SCOFF (screening questionnaire)
BMI calculator
Payment-by-results(Cluster 6)
Consider diagnosis
Co-existing substance
misuse
Communitypathway
Not require Mental Health
Serviceintervention
Requires Mental Health
Serviceintervention
Medicationreview
Psychosocialreview
REVIEWNICE
PRIORITIES
Acutecare
pathway
Requiresmaintenance
support
Assertiveoutreach/Recovery
team
CMHT
Exit from
services
NICE guideline (CG9)
Substancemisuse pathway
Assessment& risk
management
Care Pathway – Eating disorders S
peci
fic o
utco
me
mea
sure
sS
pecific outcome
measure
Eating DisorderService
Co-existing ‘borderline p.d.’
‘Emotionaldifficulties’ pathway
Self-help & caring
Medication Management
• Antibiotic Prescribing Guidelines • Cholesterol Guidelines • Choice and Medication (UK Psychiatric Pharmacists Information site)
• Clozapine initiation – inpatient & community • DVLA Guidelines on fitness to drive• Guidelines for Rapid Tranquilisation • Medicines Control, Administration and Prescribing Policy• Oral Antipsychotics • Prescribing guidelines for BPD (under development)• Prescribing Lithium• Risperdal Consta forms &monitoring guidance for clients receiving t
reatment for psychosis
ECTUser infoChoice and Medication
MIND
Psychosocial interventions
• Cognitive therapy (CBT, CAT)– 6, 12, 16, 20, 24, 1 & 2 yr sessions
• Dialectical behaviour therapy (DBT)– 48 group session group & 51 individual
sessions
• Psychodynamic psychotherapy– Group & 20 sessions, 1 & 2 yr
• Arts therapies (Art, music, dance)– 20 sessions
• Family & Couples therapy – 3, 6 & 10 sessions
• Problem-solving, Motivational interviewing; Assertiveness & Social Skills Training, Anger, & Anxiety management
All pathways(psychosis)
Emotional difficulties
Emotional difficulties
Psychosis
All pathways
All pathways
All eligible patients should be offered PI. Patient choice, non-response to previous therapy & medication, and severity determine ‘dosage’ and expertise of therapist.
Community intervention
• Support worker– Caseload 10-20
• Care coordinator– Caseload 30 (CMHT)– Caseload 15 (EIP)– Caseload 10 (AOT)– Team (CRHT)
• Psychiatrist – Caseload 2-300 (estimate)2-300 (estimate)
• Psychologist
• Roles– Engagement– Social intervention– Documentation
• Roles (include above)– Assessment – Intervention– Liaison
• Roles (include above)– Psychiatric assessment– Risk management– Diagnosis – Medication management– Care coordination
• Roles – Psychological intervention– Psychological formulation, training
& supervision
PbR Clusters & Care Pathways1
• Clusters represent stages in CPs– Emotional difficulties:
• 1: Common Mental Health Problems (low severity) • 2: Common Mental Health Problems (low severity with greater need) • 3: Non-Psychotic (Moderate Severity) • 4: Non-Psychotic (Severe) • 5: Non-Psychotic (very severe) • 7: Enduring Non-Psychotic Disorders (high disability) • 15. Severe Psychotic Depression• 6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]• 8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]
– Psychosis:• 10: First Episode in Psychosis• 14: Psychotic Crisis• 11: Ongoing Recurrent Psychosis (low symptoms)• 12: Ongoing or Recurrent Psychosis (high disability) • 13: Ongoing or Recurrent Psychosis (high symptom and disability) • 16: Dual Diagnosis = ‘Psychosis with drug abuse’ • 17: Psychosis and Affective Disorder Difficult to Engage
– Memory difficulties:• 18: Cognitive impairment (low need) • 19: Cognitive impairment or Dementia Complicated (Moderate need) • 20: Cognitive impairment or Dementia Complicated (High need) • 21: Cognitive impairment or Dementia (High physical or engagement needs)
1Cluster 9 is blank
Mental Health Training
• General practice basic CPD GMC• Management basicCPD• Mental health practitioner basic CPD• Nursing basicCPD NMC• Occupational Therapist basicCPD• Psychiatry basic CPD GMC
MRCPsych course (Wsx)
• Psychology basic CPD• Social work basic CPD GSCC
• Medical students Portal (Soton) OSCE
Training
HPFT
BipolarCare pathway NICE guidelines
Bipolar CG38Perinatal CG45
PerinatalService pathway
Five ways to well-being
1. Connect… With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in your local community. Think of these as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.
2. Be active… Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance. Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.
3. Take notice… Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.
4. Keep learning… Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you enjoy achieving. Learning new things will make you more confident as well as being fun.
5. Give … Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, as linked to the wider community can be incredibly rewarding and creates connections with the people around you.
