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«Assertive Outreach Operational Policy Authorising Officer Keith Moullin, Executive Director, Service Delivery and Transformation Signature Of ...»

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Assertive Outreach Operational Policy

Authorising Officer Keith Moullin, Executive Director,

Service Delivery and Transformation

Signature Of Authorising Officer:

Version: V2

Ratified By: OMG Policy Group

26th August 2009

Date Ratified:

Ian Scammel, Service ManagerName of originator/author:

Watford, Three Rivers & Hertsmere Name of responsible committee/lead as above


Date issued: August 2009 Review date: September 2011 Type: Operational Policy Summary: The responsibilities and service provision of the Assertive Outreach service.

Target audience: Service users, their families and carers and professionals Hertfordshire Partnership Foundation Trust is committed to providing an environment where all staff, service users and carers enjoy equality of opportunity.

The Trust works to eliminate all forms of discrimination and recognise that this requires, not only a commitment to remove discrimination, but also action through positive policies to redress inequalities.

Providing equality of opportunity means understanding and appreciating the diversity of our staff, service users & carers and ensuring a supportive environment free from harassment. Because of this Hertfordshire Partnership Trust actively encourages its staff to challenge discrimination and promote equality of opportunity for all.

Hertfordshire Partnership NHS Foundaiton Trust Contents Section Subject Page National Service Framework 3 1 Introduction 4 2 Purpose and Aims 5 3 Assertive Outreach – A Team Approach to Care 6 4 Engaging with the Service User 7 5 Team Membership 8 6 Team Locations and Opening Hours 8 7 Service User Profile 9 8 Eligibility Criteria 10 9 Referral Process 11 10 Assessment Procedures

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The National Service Framework The National Service Framework sets out the framework for the delivery of mental health services. Assertive Outreach Teams are committed to delivering the standards

set out in the framework. In particular:

Standard 1. Mental Health Promotion

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To ensure health and social services promote mental health and reduce the discrimination and social exclusion associated with mental health problems Standards 4 and 5. Effective services for people with mental illness

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To ensure that each person with severe mental illness receives the range of mental health services they need; that crises are anticipated or prevented where possible; to ensure prompt and effective help if crisis does occur; timely access to an appropriate and safe mental health place or hospital bed, including a secure bed, as close to home as possible Standard 6. Caring about Carers Aim To ensure health and social services assess the needs of carers who provide regular and substantial care for those with severe mental illness, and provide care to meet their needs.

Standard 7. Preventing Suicide Aim To ensure health and social services play a full part in the achievement of the target in Saving Lives: Our Healthier Nation to reduce the rate of suicide by at least one fifth by

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1. Introduction

1.1. Assertive Outreach Teams (AOTs) throughout Hertfordshire are part of Hertfordshire Partnership Foundation NHS Trust (HPFT). Taking a whole systems approach AOT services together with Acute In-patient services, Acute Day Treatment Units (where developed), Community Recovery Services (previously known as CMHTs) and A&E Liaison Teams, offer an integrated acute/crisis/long-term service provision

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1.4. The AOTs offer a multi-disciplinary pro-active and comprehensive service to people suffering from severe and enduring mental illness who have complex needs and have demonstrated that they are unable or unwilling to engage with other community mental health services.

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2. Purpose and Aims

Assertive Outreach Services are committed to:

2.1. Ensuring all health, social care needs and risks are assessed. That service users are managed within the Care Programme Approach (CPA) and an appropriate treatment/care plan and risk management plan agreed. The plan will include the views of the service user and relevant carers

2.2. Providing services that are accessible to all sections of the local population including black and minority ethnic groups; people with disabilities; people of both genders regardless of their sexuality; and older people. It is recognised that some minority groups are over-represented in statutory mental health services while others may face discrimination in accessing preventative, therapeutic or mainstream support services. Overcoming such disadvantage and discrimination by appropriate engagement, advocacy and a person centred flexible approach are key component of the assertive outreach model.

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2.4. Working collaboratively with, and referring appropriately to, other HPFT services such as Crisis Assessment and Treatment teams, in-patient services, Acute Day Treatment Units (when available), Community Recovery Service, Drug and Alcohol services, Forensic Services, Accident and Emergency (A&E) Liaison Services, Early Intervention Services, Community Support Teams (CST), Older Peoples Services, Community Learning Disability Teams (CLDTs), Specialist Learning Disability Services and any new services that are developed.

2.5. Enabling service users to have access to local advocacy services

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2.8. Working in collaboration with other statutory and voluntary agencies and ensuring the needs of the service user are taken into account

3. Assertive Outreach – A Team Approach to Care

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to enable the Team Manager to assign and supervise staff and adjust • the treatment and service activities allotted for that day as necessary.

3.12. The AOT maintains a written “daily log” (or equivalent) as well as a daily “team assignment schedule” (or equivalent) which is drawn up from the individual service user’s “weekly contact schedule” (or equivalent).

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5. Team Membership

5.1. The Assertive Outreach core teams unites specialist medical, nursing, occupational therapy, social work, psychology, STaR workers and administrative staff within a team base and a single management structure

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5.4. The Assertive Outreach Manager is line managed by the Service Manager (Community Services) for the relevant geographical patch.

5.5. Each team has an identified Assertive Outreach Consultant Psychiatrist

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AOTs provide services to people previously known to the secondary mental health

service and who have various combinations of the following characteristics:

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level and vulnerability. Refer to section 21 for the Trust’s committement to access to healthcare for people with a learning disability.

8.5. Service users suffering from organic degenerative condition or have a primary diagnosis of alcohol or drug dependency or personality disorder do not meet the eligibility criteria for an assertive outreach service.

8.6 Service Users who meet the eligibility criteria for Assertive Outreach should be referred to the local AOT and not held by other teams unless there are sound clinical reasons to do so.

9. Referral Process 9.1. Referral for an Assertive Outreach Service for service users known, and currently open, to mental health services should be made by the allocated Care Co-ordinator (or delegated representative) under CPA

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9.6. On receipt of the referral the AO Team Manager will conduct a screening assessment to ensure all relevant and up-to-date information is available

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9.10. A decision as to whether an AO service can be offered will be taken within 4 weeks from the date of the receipt of the referral being received

9.11. During the assessment process and until the management of care is formally transferred, through the CPA process, to AOT the referring Care Co-ordinator remains responsible for services required by the service user.

10. Assessment Procedures

10.1. Following contact with the Care Co-ordinator the AO link worker will arrange to meet the service user, with the referring Care Co-ordinator and relevant carers, to discuss the AO service, to consider the current clinical picture and to ensure all aspects of need and care have been taken into account. The AOT Consultant will be involved during the process of the assessment by discussion or by being present during the assessment with the AO link worker and the Care Co-ordinator

10.2. The link worker will be mindful that previous assessments have taken place and relevant information already available and will bear in mind that it is important service users are not subjected to having the same information requested time and time again. Nevertheless there will be a need to explore the current mental state, current risks and potential for working with the AO service

10.3. The AO assessment and the decision as to whether a service can be offered will be recorded and a copy given to the service user (if they should so wish). The Care Co-ordinator and the GP will be sent a copy within 10 working days of the assessment taking place

10.4. If an AO service cannot be offered the reasons for this decision will be fully recorded

10.5. When an AO service is offered a transfer of care will be arranged through the CPA process (see Section 11). It is the responsibility of the referring Care Co-ordinator to ensure the date for the CPA transfer meeting is set in order that the transfer of care can be expedited

10.6. If there is an unavoidable delay in the transfer of care to AOT this will be discussed at the CPA Review Meeting and an approximate date agreed for when the transfer can take place. The referring Care Co-ordinator continues to hold responsibility for service delivery until the transfer date

10.7. The AO service will ensure a member of the team will attend the transfer CPA meeting to agree with the service user and relevant carers next steps including the introduction of other team members and an initial appointment with the AO Consultant

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11. Care Co-ordination

11.1. This will be undertaken in line with the trust’s care co-ordination policy.

Care Programme Approach (CPA) is the framework under that policy for care co-ordination and resource allocation for people with complex needs requiring a multi-disciplinary response. By definition service users referred to AOT will have complex needs and will be subject to CPA rather than Standard Care.

11.2. Care Management is the framework within which social care needs are assessed and services commissioned for service users eligible to receive social care services from the local authority. Within Hertfordshire the local authorities relevant responsibilities are delegated to HPFT through Section 31 of the partnership agreement

11.3. Following comprehensive assessment of health and social care needs and a risk assessment all service users requiring a service are allocated a named Care Co-ordinator and will remain on CPA.

11.4. It should be recognised that risk cannot be eliminated; only managed. An integral part of the management process should be for the service user to accept responsibility for their own actions and associated risks supported by the Care Plan and the teams interventions

11.5. Although the Assertive Outreach Service is a team approach one member of the team will be specifically identified as the Care Co-ordinator and will hold responsibility for ensuring the agreed Care Plan is delivered and that care is co-ordinated, this will include recovery based input from a STaR Worker.

11.6. During any in-patient admission the service user will be allocated a named nurse on the ward who will work with the Care Co-ordinator to ensure needs, identified on the Care Plan, are met

11.7. CPA and risk assessment reviews will be held at regular intervals, according to need, and at no less than annual intervals. GP’s are invited to all CPA meetings and their attendance, or written/verbal feedback, at critical meetings is most important. Care co-ordinators should therefore give thought to convening these critical meetings at a time when it is reasonably possible for a GP to attend, and preferably in consultation with the GP directly

11.8. Service users and relevant carers will be fully involved in discussion of the Care Plan and will be asked to agree the contents. They will have a copy of the plan which will include details of the Contingency Plan identifying risk factors, warning signs and agreed actions to be taken when concerns arise at home or work. The care plan which will be focussed, person centred and address all health and social care needs; including needs relating to ethnicity, gender, age, disability, sexuality and spirituality.

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11.9. Carers needs will be identified and a carer’s assessment offered and arranged if this is required and desired.

11.10. Transfer of care to another area will be managed by the Care Co-ordinator according to policy guidelines

11.11. The AO Service will follow all procedures outlined in the Hertfordshire Partnership Foundation NHS Trust Policy “Care Co-ordination” including the transfer and closure of cases.

12. Medical Responsibility

12.1. When the AOT have accepted responsibility for the service user and the transfer of care has been agreed within the CPA review meeting the Consultant Psychiatrist attached to the AOT will be the Responsible Consultant and hold medical responsibility.

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