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Margaret Fleming Monaghan

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					Developing a Community Based
Mental Health Service in a Rural
         Community

                Margaret Fleming
               RPN, FFNRCSI, MSc
International Mental Health Collaborating Network
                    (IMHCN)
      SETTING THE CONTEXT
 Ireland

 How Health Services are Delivered in Ireland

 Cavan Monaghan Mental Health Service

 Change Management/Whole Systems Working

 Community Mental Health Teams

 Home Base Treatment

 Evaluation

 The Question ?
Ireland

Health Service Executive Areas
Health Service Executive Ireland
 Cavan/Monaghan
Mental Health Service
CAVAN/MONAGHAN MENTAL HEALTH
          SERVICE

               POPULATION 119,000

               TOTAL SQ. KM.3,300

               DEPRIVATION RATE
               CAVAN 10.7%
               MONAGHAN 4.7%

               BUGET 17 MILLION EURO

               PER CAPITA 143 EURO
  Change Management
WHOLE SYSTEMS APPROACH
                PRINCIPLES
• A specialist service
• A service with a single point of access that is
  easily accessible, available and responsive
• A service which has at it’s core the primacy of
  service users needs and rights
• A service which delivers an individualised
  effective treatment package in the setting of
  home and family
              Core Elements of Service
                      Structure
4 Functional Specialist Teams

•     Monaghan Community Mental Health Team with Home Base Nursing

•     Cavan Community Mental Health Team with Home Base Nursing

•     Community Rehabilitation Team with Assertive Outreach Nursing

•      Psychiatry of Later Life with Home Base Nursing
CAVAN/MONAGHAN MENTAL HEALTH
          SERVICE

               POPULATION 119,000

               TOTAL SQ. KM.3,300

               DEPRIVATION RATE
               CAVAN 10.7%
               MONAGHAN 4.7%

               BUGET 17 MILLION EURO

               PER CAPITA 143 EURO
     REFERRAL SYSTEM PRE 1998
                          REFERRING AGENTS

                        CONSULTANT PSYCHIATRISTS

OCCUPATIONAL THERAPY                            ADDICTION COUNSELLORS



  BEHAVIOURAL THERAPY                          FAMILY THERAPY


          SOCIAL WORKERS                       NURSES / CPN

                               PSYCHOLOGISTS




                           REFERRING AGENTS
   COMMUNTIY REHABILITATION TEAM (POP. 119,000)
                   PSYCHIATRY OF LATER LIFE
                     ADDICTION SERVICES




                                                     Community
                                                    Mental Health
                                                       Team

                                      Monaghan


                                                Carrickmacross
                        Cavan
Community Mental
  Health Team                   Bailieborough
         TEAM BUILDING


 Meetings
 Operational policies
 HBTT /gatekeeper of Acute Beds
 Single point of access
 Multidisciplinary team
 Service Directory
BIO PSYCHO SOCIAL MODEL


           Mental distress does not occur
            in a vacuum but in the context
            of peoples’ lives.

           Context gives meaning
     Creating Partnerships


 With Service-users
 With Carers/Families/Significant others
 With G.P’s
 Reassurance
 Action
COMMUNITY MENTAL HEALTH

          Mental health is a community
           issue
          A community resource based
           model has at its foundation
              Housing
              Employment
              Education
              Income
ELEMENTS OF CITIZENSHIP

           Rights to:

                Equality of opportunity
                Economic security.
                Justice and respect.
                Freedom of speech.
                Freedom of choice.
                To be an individual.
                Self-determination.
Developing Collaborative Alliances
     Within the Community

 Meetings

 Interagency networking

 Collaboration

 Coalitions
BIO-PSYCHOSOCIAL MODEL OF
           CARE
   Service-user centred
   Service-user ownership
   Importance of involving the family / significant others
   Recognising social and personal resources
   Community as a resource to encourage and promote
    normal social relationships
   Empowerment
   Participation
   Collaboration / Interagency
   Interdependence not independence
     Community                                                   Gardaí
       Care                           Acute
                                    inpatient                        Solas
Primary care                                     Admin

                 S.W.                     CPN
Self Help                  H.B.T.                                     Advocacy
                                                     Addiction
                 Medical
                 Secretaries
                                SERVICE                                   Housing
                                                   Family
                                USER               Therapy
  Youth     Management
  Groups                   Medical
                           Team           O.T.                    Women’s Groups
                                                 Behavioural
 Eemployment
                                                 Therapy
                               Psychology                            Education

     Voluntary                                       Health promotion
      groups
             Service
              user


         Family / carers

            Community

    Mental health professionals

 Primary care / social services

Voluntary / statutory organisations


      National community
Community Mental Health Teams
   COMMUNTIY REHABILITATION TEAM (POP. 119,000)
                   PSYCHIATRY OF LATER LIFE
                     ADDICTION SERVICES




                                                     Community
                                                    Mental Health
                                                       Team

                                      Monaghan


                                                Carrickmacross
                        Cavan
Community Mental
  Health Team                   Bailieborough
               MONAGHAN
         Community Mental Health Team

 1 Clinical Co-ordinator             1 Occupational therapist
 2 Consultant psychiatrist           1 Psychologist
 1 Senior Registrar                  1 Social worker
 3 Registrar                         4 Addiction counsellors
                                      Acute unit
 6 Home based treatment team
                                      Day Hospital
 1 Community support worker
                                      Service-user Resource Centre
 3 Community psychiatric nurses      Advocacy
 1 Secretary
 1.5 Cognitive Behavioural
  Psychotherapists
 2 Family therapists
     REFERRAL PATHWAY
MONAGHAN CAVAN COMMUNITY MENTAL HEALTH TEAM

                       PRIMARY CARE


                    TEAM CO-ORDINATOR


     PSYCHIATRIC EMERGENCY      MULTIDISCIPLINARY TEAM


     H.B.T. / ACUTE INPATIENT




   COMMUNITY REHABILITATION TEAM
                         Acute
                       inpatient
                                     Admin
   Social
   Worker                     CPN
              H.B.T.
                                         Addiction
    Medical
    Secretaries
                   Clinical            Family
                   Coordinator         Therapy
Management
              Medical
              Team            O.T.
                                     Behavioural
                                     Therapy
                  Psychology
HOMEBASE TREATMENT
HOME BASED TREATMENT TEAM
    MISSION STATEMENT


 The Home Based Treatment Team aims to work intensively
     in a focused way with service-users and their families
  during the acute phase of their illness, incorporating a care
  programme approach to treatment and supporting clients in
            reaching their optimum level of recovery
               Purpose of
          Home Based Treatment
•   Gate Keepers of Acute Beds

•   Alternative to Hospitalization

•   2 hour response time

•   Crisis focused

•   Facilitates Early Discharge from Hospital
      RECIPROCAL PROCESS OF
          EMPOWERMENT

                   Empowerment
    Confidence                       Information


 Self Esteem                                Choice


Self Value                               Decision Making


  Accountability                       Control
                    Responsibility
Home Based Treatment is Recovery
          Orientated


        15%      30%

        15%      40%
HOME BASED NURSING IS
BUILT ON PARTNERSHIPS
              Service users
              Families
              Significant others
              Choice
              Participation
              Collaboration / Interagency
              Interdependence not
               independence
             Core competencies
 Respect for people experiencing mental distress and their
  families.
 Understanding of the most effective approaches and of the
  societal, community, and system factors affecting recovery.
 Knowledge of a variety of treatment and support
  strategies.
 Ability to design and deliver individualized supports with
  an emphasis on (non mental health) resources and to
  access and employ those resources.
 Holders of hope, self-respect and self-esteem.
 Belief in recovery.
 Determination, tenacity, persistence, faith and love.
            Home Base Procedure


 Referral to Community Mental Health Team
 Joint assessment by HBT nurse and medical staff
 Determine if HBT can be an option
 Joint plan of care drawn up, incorporating supports i.e.
  family/carers
 Level of support decided jointly with service-
  user/family/HBT and medical staff
 Contractual arrangements with service-user and family/
  carers agreed.
 HBTT Nurse Then:
Arranges earliest possible home      Builds a trustworthy relationship
visit                                with service-user and family


Meets with family and carers         Maintains a proactive role
                                     throughout treatment
Carries out assessment i.e. FACE     Service-user and relatives are also
www.face.eu.com/our-                 given verbal and written
                                     educational/self-help information
products/assessment-
tools/mental-health-
assessment-toolset
Liaises closely with medical staff   HBT liaises with other disciplines
                                     to ensure follow up care after
and team leader.
                                     discharge

HBTT meetings twice weekly
There are three levels of support:

•Intensive
Able to spend time flexibly with service-user and social network
including several visits daily if required

•Less intensive
alternative days, twice weekly

•Continual Care
once weekly/fortnightly

       Housing
       Employment
       Benefits
       Medication management
   CRITERIA FOR INTRODUCTION OF HOME-BASED
                   TREATMENT


 The service-user has been identified as being acutely
  mentally ill with a risk of further deterioration
 There is a perceived need for admission to hospital
 The needs of the service-user cannot be met by the key
  worker/ team because of increasing complexities
 Service-user/family/carer is agreeable for Home
  Treatment nurse/team to implement a care
  programmed.
 THIS WORK IS ACHIEVED BY PROVIDING A
   VARIETY OF SERVICES AND SUPPORTS
               INCLUDING

 Quick response on referral – 2 hours
 Joint assessment at home or at venue of choice
 Discussion and planning of a care programme with
  service-user and significant others
 Explanation, advice and support to service-user and
  family re nature of illness, treatment and expected
  outcomes
 Intensive support to service-user and family
 Encouragement of normal activities where possible
 Crisis work with the service-user and family including coping
  strategies

 HBT remains involved throughout the crisis until it’s resolution

 Constant review of progress by involved disciplines

 Gradual withdrawal with recovery and linking up to further
  continuing care
     WHY HOME BASED TREATMENT?
  “Home based treatment is a safe, effective and feasible
   alternative to hospital care for up to 80% patients with
   acute psychiatric disorder and one that they and their
                   carers generally prefer.”
                   (Smyth & Hoult, 2000)

 It provides a proven research based alternative to hospital
  admission
 Avoids the trauma of admission on the service user and their
  family
 Provides choice for service users
 Upholds civil liberty
 The clinical benefit is the same or better
 It decreases the stigma attached to hospital admission
 Assessment of needs are more social based
 Assistance in addressing social issues surrounding the
  crisis from the beginning
 Can provide practical problem solving help
 Avoids lengthy hospitalization
 Greater service-user satisfaction often resulting in better
  engagement and concordance
 Greater family/carer satisfaction, education and support
 Avoids residual symptomatology sometimes associated
  with hospital admission
                                                     Personal details
                       GP Details                    Affix label here




                                    key worker's):
                                    Consultant;

referral details




treatment to date




ICD 10 Diagnosis




medications on discharge




discharge plan
     Community                                                   Gardaí
       Care                           Acute
                                    inpatient                        Solas
Primary care                                     Admin

                 S.W.                     CPN
Self Help                  H.B.T.                                     Advocacy
                                                     Addiction
                 Medical
                 Secretaries
                                SERVICE                                   Housing
                                                   Family
                                USER               Therapy
  Youth     Management
  Groups                   Medical
                           Team           O.T.                    Women’s Groups
                                                 Behavioural
 Eemployment
                                                 Therapy
                               Psychology                            Education

     Voluntary                                       Health promotion
      groups
EVALUATION
Overall feeling about the cooperation between
               service providers

                                      Mostly
                                    Dissatisfied
                        Excellent       5%
                          27%




                                          Mostly Satisfied
                                               68%


 Mostly Dissatisfie d               Mostly Satisfie d        Exce lle nt
               Overall view of confidentiality and respect shown for clients rights

                            GP                         CARER                    CLIENT

          70

          60

          50
percent




          40

          30

          20

          10

           0
                 terrible        mostly dissatisfied      mixed   mostly satisfied       excellent
              Overall level of satisfaction with the service.

     Mixed                        Mostly satisfied                       Excellent

70


60

50


40


30


20

10


0
         GP                           Carer                     Client
        The response of the service to crsis or urgent needs.

     Mixed                 Mostly Satisfied            Excellent

70


60

50


40


30


20

10


0
         Patient                     Carer                   GP
   Rates per 100,000 of the Population
                   Activities of Irish Psychiatric Hospitals 2009



HSE Area                  All Admissions                   Involuntary Admissions




HSE Dublin North East     449.1                            31.3




HSE South                 508.0                            43.7
Admission Rates per 100,000 of the
           Population
        Activities of Irish Psychiatric Hospitals 2009
Admission Rates per 100,000 of the Population
              Activities of Irish Psychiatric Hospitals 2009
         1st Admission Rates per
        100,000 of the Population
           Activities of Irish Psychiatric Hospitals 2009




Monaghan                           44.6


Cavan                              81.2
Type:
Go to the people
Live among them
Start with what they know
Build on what they have




                                                                  Be of the best leaders
                                                        When their task is accomplished
                                                                     Their work is done
                                                                  The people all remark
                                                             We have done it ourselves

 Copyright - Cavan Monaghan Mental Health
 Service                                    THANK YOU
WHAT FACILITATES
  RECOVERY ?


  15%   30%

  15%    40%
    MANAGEMENT STYLE

      TRADITIONAL STYLE


TOP DOWN SUPERVISORY CONTROL
  MINIMAL NEED FOR DISCRETION
 RELIANCE ON RULE, JOB SPECIFIC
     RIGID, LITTLE INFLUENCE
LEADERSHIP MANAGEMENT STYLE
                      HORIZONTAL


                          TEAM
   EQUALITY, COLLECTIVE, COLLABORATIVE, COMMUNICATIVE
                         (Working)


           SHARED PLANNING, RESPONSIBILITIES
             ACCOUNTABILITY AND OUTCOMES


                  FLEXIBLE, COMPETENT
              AUTONOMOUS, DECISION MAKING


           MOTIVATION, INNOVATION, CREATIVITY
           OPEN TO CHANGE, JOB SATISFACTION
         REDUCED DEMANDS ON MANAGEMENT TIME
Citizenship
Recovery
Risk
Leadership
Belief
Engagement Thinking outside the box
Organisational Culture
Management horizontal versus Bureaucratic
Over managed
Autocratic
Mutual Respect
Collaboration
Partnership

				
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