Sample Clinical Pathway Team Protocol OATs by 8f474YN


									April 2006                                                               Appendix 1
Reviewed January 2008
Reviewed December 2009

                Rehabilitation and High Support Directorate
                               Clinical Pathway Team
                         Assessment and Monitoring Protocol

1.          Introduction

The Rehabilitation and High Support Directorate aims to develop a range of
services that will reduce the overall dependence upon out-of-area placements
for individuals with complex mental health needs.

The National Service Framework (NSF) for mental health emphasises the
need for access to local services. Standard 5 states:

            ‘Each service user who is assessed as requiring a period of care
            away from home should have timely access to a hospital bed or
            an alternative placement which is in the least restrictive
            environment consistent with the need to protect them and the
            public and as close to home as possible’.

The Clinical Pathway Team aims to:

     i)        Facilitate the return of people in out-of-area placements
     ii)       Reduce future dependency upon out-of-area placements
     iii)      Bring financial benefits to partner agencies
     iv)       Provide advice and support in identifying appropriate pathways for
               individuals with complex mental health needs

2.          Role and Function of the Clinical Pathway (OAT) Team

The Clinical Pathway Team will undertake to ensure up-to-date and accurate
information is made available to the Rehabilitation and High Support
Directorate senior management team to enable the future planning of services
to be based around identified continuing health and social care needs of
individuals to ensure the best possible outcome for each individual.

The team will focus on service user who have complex mental health needs
and frequently present behaviour that is deemed challenging to existing
mental health services. It has been recognised that this group of service user
will require different levels of physical or relational security in either the short,
medium or long term period of time depending upon their individual clinical

April 2006                                                         Appendix 1
Reviewed January 2008
Reviewed December 2009

The Team will operate from the Rehabilitation & High Support Directorate and
provide specialist advice regarding alternative pathways for individuals where
there is rehabilitation need identified. This may result in agreed admissions
within existing provision or a suggestion of more appropriate services. The
team will work in conjunction with care co-ordinators and Responsible
clinicians; clinical teams and other agencies where necessary. The aim will be
to ensure good communication is maintained and that the work undertaken by
the team is viewed as an additional specialist resource to aid and support
clinical care planning and effective risk management formulation and
developing appropriate care pathways for service users.

The team aims to:

      Identify potential cohorts for reprovision
      Maintain an accurate and up-to-date database of all the cohorts from
       each of the Boroughs
      Carry out a range of holistic clinical assessments to identify need
      Identify risk areas and issues related to individual clients
      Participate within a multi-disciplinary process of future placement
      Monitor and advise on current secure placements and encourage
       moves into less secure environments supported by intensive packages
       of care where necessary
      Liaise with the range of service commissioners, providers and statutory
       and non-statutory agencies involved with service users
      Ensure on-going communication with North West Specialist
       Commissioning Team, local PCT, Borough leads and clinical teams
       regarding secure placements.
      Provide support and advise to commissioners, care coordinators/key
       workers in future planning and the development of complex packages
       of care
      To attend CPA/ECC reviews where required
      To use agreed standards of documentation, care planning, risk
       assessment and record keeping.
      Maintain a reporting system that provides detailed information on
       current placements and care plans when requested.
      To undertake reviews of service users awaiting admission, and to
       complete pre-admission work with service users identified for
       admission to the range of F&HS in-patient units.

3.      Assessment Process

The Clinical Pathway Team will undertake a range of informal and formal
assessments of clients in a number of different settings within the Trust
footprint but also in OAT placement across the country:
    Low secure units
    Medium secure units
    High secure hospital
    Specialist Learning Disability Hospital
    Nursing Homes

April 2006                                                         Appendix 1
Reviewed January 2008
Reviewed December 2009

     Psychiatric Intensive Care Units (PICU)
     HM Prisons
     Acute mental health services (clients awaiting transfer to a secure
     Residential homes

The types of assessments undertaken include:

    i) Initial Assessments
       The initial assessment will be undertaken on all service users referred
       to or identified by the team. This assessment involves scrutinising the
       MDT clinical record; discussion with care team members and the client
       if deemed appropriate to do so. Information is recorded on a
       standardised assessment form and captures information related to
       specific areas:
            Historical information
            Current symptoms
            Current problems
            Current interventions
            Risks associated with illness
            Psychiatric medication
            Physical health problems
            Family relationships
            How the illness affects the client
            Reason for OAT placement
            Summary of the assessment
            Recommendations for future services.

   ii) Specialist Assessment
       The specialist assessment involves a more in-depth assessment with a
       greater focus upon service user engagement and the assessment and
       management of risk. This assessment involves a more structured
       approach to ensure reliability and accuracy of the information and the
       final outcome of the assessment by utilising a range of specific
       assessment tools. The assessment process requires the practitioner to
       have good clinical management as well as skill, experience and
       careful judgement, applied to a sound base of information and
       knowledge. The assessment should include:
            Historical factors related to the development and course of their
            Rehabilitation history related to their offending behaviour
            Current mental health/behaviour presentation
            Circumstances of their current placement
            Current plan of care
            Past effective and ineffective interventions
            Early warning and relapse indicators
            Unmet needs
            Level of support needs
            Carer or support networks

April 2006                                                           Appendix 1
Reviewed January 2008
Reviewed December 2009

             Risk assessment, including identifying protective factors
             Rehabilitation need
             Recommendation for future services

4.      Information and Case-Load Management

The management of the Team’s case-load is undertaken on a weekly basis. A
centrally managed database holds the relevant information regarding all
OATS from the surrounding boroughs across Pennine’s footprint. This
information system is up-dated on a regular basis following each visit by a
pathway nurse. The database includes:
     Client name
     Responsible PCT
     DOB
     DOA
     Diagnosis
     Current Placement
     Type of service
     Care Co-ordinator
     Future need (type of service)
     Date of next CPA
     Cost of placement

It is critical that the information is regularly up-dated as the OATs list can be
very dynamic. Those individuals in long term placements will be reviewed on
an annual basis; medium term placements 3 – 6 monthly and short term as
required. The monitoring timescales provide the team with guidance on
frequency of reviews but can be flexibly operated to facilitate a more robust
monitoring process where necessary. The stored information will be validated
with PCT leads at borough monitoring meetings and the recommended
outcomes of assessments will be discussed. The allocated nurse will ensure
regular attendance at CPA reviews and other clinical review meetings if
deemed necessary and ensure the relevant stakeholders receive a written
report of any potential pathway recommendations.

The Pathway Team operates from a team approach basis with each
practitioner taking a lead role in an allocated case but with involvement from
other members when necessary. Case-loads will be reviewed during the
OATs Meeting which is chaired by the Pathway Manager/Deputy. The
meeting provides a forum for team discussion, sharing of information, an
exchange of views and combines the experience and expertise of each team
member. Decisions are recorded and future plans detailed in individual case

Where a pathway is identified that indicates an internal placement would be
appropriate, the RHSD Referral process will be implemented. In cases where
an alternative pathway is through other services the process will be
communicated to the care co-ordinator and assistance made available to
facilitate the necessary PCT process.

April 2006                                                        Appendix 1
Reviewed January 2008
Reviewed December 2009

5.      Service Development

A major component of the Pathway Team’ role is to collate information related
to OATs and to utilise that data to create opportunities to establish local
developments through local Service Development Groups; commissioning
meetings and joint planning initiatives. The fundamental aim being to ensure
services uses have access to locally developed rehabilitation services.

     Joyce Parkinson
     Divisional Clinical Pathway Manager


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