Integrated Mental Health & Well-Being Community - Model of Care Mental Health Programme Board 13 th November
1. Contents 1. Context 2. Case for Change 3. Aims of New Model of Care 4. Whole System View: ‘to be’ Mental Health Pathways on a page. 5. Integrated Community Pathway: Model of Care on a page 6. Building Blocks: more detail on the core elements of the Model of Care 7. Case Study 1: ‘before and after’ 8. Case Study 2: ‘before and after’ 9. Next Steps 2
1. Context • Prevalence of long-term, complex mental health needs higher in Croydon than the national average, with an NHSE mental health needs index of 1.21 (where 1.0 is the national average), making it comparable to many inner-London, high-prevalence Boroughs such as Westminster and RBKC. • The CCG has a registered Serious Mental Illness Population of 4,506 people, or 1.11% of the adult population ( ibid ). In addition, whilst no formal GP register exists, there is a significant group of people with complex non-psychotic conditions such as severe anxiety, depression and personality disorders who, due to their presenting behaviours and relative paucity of service responses, can pose a greater management challenge than those with a stable long-term SMI. • Need profiles vary across the Borough, from more affluent areas to more deprived, each presenting mental health and well-being support needs. Any service developments need therefore to be locally sensitive and able to respond to such variance through being locality and community-embedded. 3
2. Case for Change • Existing secondary pathway isn’t working: too long to wait, multiple teams. • People want a non-clinical-feeling service that offers hope, solutions, expert welfare help, joined up and wrapped round them. • Need a service that helps avoid crises and reliance on secondary (A&E and MHT) • Need a resource to properly support primary care and General Practice to promote and retain well-being and recovery: social, mental & physical well-being. • Many patients end up in A&E despite lack of physical need. A GP advice line would be very helpful. • Existing community resources seem fragmented and hard to navigate: multiple referrals with GP/patients/carers having to self-navigate the system. • GPs need more time to go ‘above and beyond’ for complex MH needs patients: bio - psycho-social care planning with follow up time, in-year review, measuring impact. • Seamless, singular access route needed for assessment and access to SLaM. • Need to co-locate services and staff in Hubs for integration, but have far-reaching community spokes to ensure they are accessible and localised. 4
3. Aims & Objectives of the new Model of Care • To attend, with equal weight, to the social, physical and mental health needs as defined by the service user, carer and their GP. • To act as a single point of entry to the whole mental health system, via a cross- agency ‘front door’ approach. • To provide a diverse range of timely, accessible services that support recovery, resilience and instill hope. • To reduce mental health crisis escalations and reliance on urgent & acute care. • To provide a proactive, valued resource for its members that encourages them to use the service proactively, supporting their self-efficacy to manage their continued recovery and avoid crises. • To integrate service delivery across existing providers and General Practice, delivering a whole system/’one Croydon’ approach. • To underpin the new model with a new enhanced GP service: paid extra time for an annual ‘Well - Being plan’, in year reviews and single care record on EMIS. • To co-locate and deliver services across a number of community- based ‘Hubs’ and ‘Spokes’, ensuring maximum accessibility and joint -working with existing community groups. 5
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High Level Description of Integrated Mental Health & Well-Being ‘ Building Blocks ’ Provider Assessment, Clinical Case Management, GP Liaison/Advice Line. TBC Psychiatrists and CPNs/SWs/OTs. The single MDT ‘ way in ’ to access all primary and secondary MH services. Rapid triage, assessment, formulation and care planning/treatment entry (directly to secondary care if indicated). Key offer: case management & brief intervention (up to 6 sessions) & advice line/liaison for GPs. Navigators TBC Team of expert health and social care navigators to work alongside the clinical team within the MDT approach. Coordinates and supports delivery of social elements of care and support (housing, debt, welfare, employment, training, CAB etc). Typically 2-3 contacts max. Employment Support TBC Expert service to support people to keep jobs, re-join the workforce, train or volunteer. Provides 121 mentoring and workplace support, help with applications, CVs, interview support, group training. Coordinates link to wider employment initiatives across the Borough in pursuit of ‘ no wrong front door ’ approach. Psychological Therapies TBC Direct access to Step 2, 3 and 4 psychology from Primary Care and the Hub. Using a reciprocal ‘ hub and spoke ’ approach, existing services delivered in Hubs and other community settings, including larger GP Practices. Promotes access to ‘ IAPT ’ services via better community integration and targeting of 65+ and key LTC groups. Peer Support TBC Centrally located development workers who will provide a range of peer support activities including time- banking, mentoring programmes, skills-swaps, befriending, a volunteer pool, and coordination of activities. Self Help/Self Care TBC Literature, group-based (guided) and on-line self-help to support and maintain recovery and well-being. A range of coordinated self-care activities such as gym/swimming club membership/passes and also massage, acupuncture, mindfulness meditation to be made available at Hubs and existing community settings. Connected: Social Activities TBC Coordination and promotion of a range of supportive activities that reduce social isolation and support mental health and well-being through participation, creativity, achievement and ‘ belonging ’ (e.g. yoga, gardening, walks, social and community events such as theatre, arts trails, etc). Web-based platform for booking. GP Enhanced Care TBC A new GP specification will be the bedrock of a proactive/preventive population-based approach. An annual ‘ Well-Being & Recovery ’ Review and Plan (Bio-Psycho-Social) for all those with long-term complex mental health needs (SMI + Complex Non-psychotic needs). Extended appointment times up to 3 x 30 minutes.
6a. Before and After Case Study (1) Amy is 37. She has had a diagnosis of Schizophrenia for 15 years and has been living very stably for the last decade when she presented to her GP distressed, feeling paranoid and like she was losing control of her life. Having lost one of her two part-time jobs she has fallen into arrears with her Housing Association. She ignored the last two letters, but on Friday received a letter threatening her with eviction should she fail to respond to this final notice. She is also being depressed about the weight she’s gained on her medication, and she admits to skipping doses and to smoking cannabis to help her relax, due to the stress. Amy’s GP is very concerned about her mental state and welfare. Amy’s GP sends a ‘task’ via EMIS to ”The Hub”, Croydon’s one - She feels that a medication review is essential and agrees to stop shop for mental health and well-being, requesting a same- day call back with a Psychiatrist to discuss Amy’s medication. A refer her back to her old CMHT for this. The waiting time to be seen is roughly 10 weeks, she is told, and they will contact Amy full review is agreed, considering options that have fewer cardio- metabolic side effects to take place at The Hub’s north base. directly at her address. Imminent risk of losing a tenancy is not an urgent referral criteria. At the same time the GP updates Amy’s “Well - Being Plan” with Her GP then advises her about a Citizen’s Advice service run by the latest information following their consultation. She is able to identify from ‘The Hub’ website when the next Housing Advice the Council and suggests she goes there to get support with her flat, and suggests they may also be able to give her debt advice. session is running and arranges for her to see a Navigator later They can also be accessed on-line. that day. They agree to meet the Housing Association together. She asks Amy if there are other ways to relax that she enjoys, In notes, her GP advises that Amy is feeling socially isolated and rather than relying solely on cannabis. She used to enjoy yoga would likely benefit from some time with the Navigator and with but got out of the habit and now feels unsure about how she Peer Support to access the weekly yoga sessions that are free could afford to attend a class, and also feels that people would to Members. When Amy is meeting the Navigator in the café talk about her. space, she recognizes someone she once knew well from Rehab who’s also going to yoga. She agrees to pick Amy up so They agree to meet again in a week but Amy doesn’t attend that they can walk to there together. appointment. Four months later the GP gets a letter to say that Workers at the Hub update her “Well - Being Plan”, which is then she has just been discharged from an in-patient ward and is available when the GP sees Amy in a week’s time to review. moving in to supported accommodation for a year. 9
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