City and Hackney Community Rehabilitation and Recovery Service - East London NHS Foundation Trust - HC - #MHAwards19

Please briefly describe your project, group, team or service, outlining What you do and why it makes a difference

We are an MDT based in the community with a mix of medical, nursing, social work, OT, psychology and support worker time. The work we do is in the context of integrated mental health and social care with East London Foundation Trust managing the budget for CCG complex care and the mental health supported accommodation budget for London Borough of Hackney. Our rehab service is unusual in that we do not have any inpatient rehab beds in our Trust (London Boroughs of City & Hackney, Tower Hamlets and Newham) and through working closely with clinical colleagues, the local authority and accommodation providers we are able to support people within the community who might otherwise become long stay patients on inpatient units. This model relies heavily on the strength of our relationships with other agencies and the assertive approach we use in trying to find the right fit for individual patients in terms of their accommodation and broader care. We believe that this promotes independence through allowing people to be supported to live within the local community.

As a community rehab service our current functions are broad:

· Care co-ordination of 70 patients – severe and enduring mental health illness with prominent positive and negative symptoms of schizophrenia, treatment resistance and poor functional level in activities of daily living (ADL).

· Provide clinical input to run an Occupational Therapy led rehabilitation programme from one of our supported living projects in the community (11 beds) in partnership with a support provider. People usually stay 6 months – 2 years and we have the opportunity to thoroughly assess and provide an ADL development programme in a community setting.

· Oversee the operation of City & Hackney’s clozapine clinic (268 people)

· Placement Review Service– we carry out annual review of all funded placements on behalf of LBH and CCG using our placement review tool and plan and support step down if appropriate. We carry out approximately 130 annual reviews. We review all funded placements (ELFT mental health/complex care and LBH mental health supported) – supported living/residential/nursing and review both spot-purchase and block-funded provision, in and out of borough. The aim of the placement review is to gather information on service user views, suitability of the placement and potential for step-down. The review may include assessment of mental capacity. Reviews are completed jointly by medical staff and OT/SW/CPN. As well as the service user we invite families/carers, care act advocacy and MH community teams where appropriate. We have a fortnightly MDT placement review meeting where we agree and record actions and allocate for case management when indicated.

· Case management – we take on people from the placement review work for active case management where no care co-ordinator or clinical team is involved or when a specific task we have expertise in needs to be completed (includes DOLS, safeguarding, appointeeship, capacity assessment, supporting providers, physical health problems, court of protection, family liaison and moves within and back to borough)

· Inpatient liaison + assessment – we receive referrals via bed management processes to facilitate timely discharge by identifying placements and signposting panel processes swiftly

· Hackney Mental Health Supported Accommodation Panel – co-facilitating the panel, managing admin support, liaising with providers across the pathway, housing quota allocation

· Pre-panel consultation/ assessments – referrals for discussion about appropriate accommodation options for community teams including forensic stepdown options

· Developing a wider focus on supported accommodation in the community – providing CHC (continuing health care) team support with mental health and challenging situations, current HEE funded project to scope training needs of all supported accommodation in Hackney (including nursing homes, LD placements, older adult settings)

· Reablement work – we have developed a model of reablement in the context of mental health supported accommodation and have been delivering that to a cohort of people funded by City of London. Outcomes of this work have been to help step down people living in high cost supported settings for many years and promote independence.

· We are also fully involved in procurement of new providers for all stages on the accommodation pathway allowing us to contribute the clinical perspective and shape the services we need for our population

What makes your service stand out from others? Please provide an example of this.

We are one of three Mental Health Trusts rated ‘Outstanding’ by the CQC (this recently became four with Herts Partnership).

Our service stands out because for City & Hackney we have

· no inpatient rehabilitation beds,

· no out of area rehabilitation beds,

· no private bed use for adults with mental health problems

· no use of acute ECR beds (for many years)

Alongside this we maintain a lower than English average length of stay on acute wards (City & Hackney 28 days).

How do you ensure an effective, safe, compassionate and sustainable workforce?
Our compliance with mandatory training is high. We promote and encourage CPD activities across all members of our team. We have an excellent level of staff retention. Our highest turnover tends to be among support workers who gain experience and go on to higher skilled appointments. We follow Trust policy in terms of staff safety and wellbeing. The Trust offers a range of initiatives to promote wellbeing that we access. In addition we are participating in a QI project aimed specifically at improving the wellbeing of staff using weekly questionnaires to establish if the team members have had a ‘good week’ or a ‘bad week’ and asking for people to share why. We then use this information to guide initiatives within our team. For example, we have started a monthly evening cinema group and weekly running group for staff. This project is ongoing. Supervision and appraisal is guided by the trust’s Supervision policy. Planned and regular one to one management supervision takes place on a minimum monthly basis. A written record of the supervision should be recorded and signed off by both parties. A yearly appraisal is provided with a three monthly review of appraisals. Management supervision This is focussed on an individual’s overall workload, functioning within the team and maintaining clarity about role, responsibilities and accountability. The operational lead provides management supervision to the two Band 7 Senior practitioners. Band 7 Senior practitioners supervise the Band 6 staff. Support workers and Band 5 Staff are supervised by Band 6 staff. Management supervision is not profession specific. Professional Supervision All members of the team have the option to have professional supervision. This is focussed on the working relationship between the clinician/professional and individual service users and their carers/ family. It is an opportunity to systematically reflect on and understand the needs of the service user and carer and consider the practitioner’s interventions and responses in the work. We have monthly formulation sessions with our team Psychologist to discuss complex cases. This allows the MDT to discuss and support each other with complex patients and allows time for reflection. We have a peer support worker as a permanent member of staff, part-time. The support worker role is crucial in the work we do in many ways but particularly in working with our patients to live within the community and when stepping-down from higher support accommodation to more independent placements. Having a support worker with lived experience is invaluable in engaging with some of our more isolative patients.
Who is in your team?	Band/grade	Number	Whole-time equivalent
Operational lead	B8	1	0.8
Senior practitioners (currently OT and CPN)	B7	2	2
·Social workers (care coordinator role) –	B6	3	3
Community Psychiatric Nurse (care coordinator role)	B6	2	1.6
· Consultant Psychiatrist		2	1.2
· ST4-6 Doctor		1	1
· ST1-3 Doctor		1	1
· Specialty Doctor		1	0.8
· Occupational Therapist	B6	2	2
· Occupational Therapist	B5	1	1
· Support Workers	B4	2	2
· Peer Support Worker	B3	1	1
· Psychologist	B8	1	0.4
· Administration support (shared with other services)	Various Tbc	2	2
· Placement and Panel co-ordinator	Tbc	1	1

How do you work with the wider system?

The success of our team relies heavily on our role within the wider system. The strength of our partnerships with other organisations is paramount. As a specialist team we receive referrals from all the locality teams in Hackney as well as the inpatient wards. We visit community teams on a regular basis to encourage referrals and take an assertive approach to supporting those teams with patients who have complex needs and find it hard to settle in a place. We believe that this helps to avoid admissions and plays an important role in maintaining a community based focus for rehabilitation and recovery.

Our role in the housing panel includes hosting the bi-monthly housing panel which advises on appropriate placements for patients funded by the London Borough of Hackney (LBH) for mental health needs. We have attendance from the lead commissioner for LBH, the Deputy Borough Director and representatives from the main accommodation providers. Through this we have good relationships with those providers and maintain a ‘live’ knowledge of where there are placement vacancies. In addition to the panel itself, we provide a pre-panel discussion option so that care coordinators can discuss complex patients before presenting them which often results in a more useful discussion and aids swift decision making. We have had very positive feedback since introducing this from those using the pre-panel slots. We have a pro-active approach to improving the process by gathering feedback from care coordinators. Our QI project on the accommodation pathway has led to us testing a number of change ideas including updating and refining the forms we request care coordinators to fill out when they present their patients and changing the way we record panel outcomes.

The case management function of our team means working closely with mental health clinical colleagues and supporting them with accommodation issues. These are usually patients who are not care coordinated by their locality team but for whom there may be complexities or challenges around their accomodation. As case managers we can arrange capacity assessments where needed, appointeeship applications and help to facilitate accommodation step-downs. We took on this role to reduce delay in appropriate move-ons that we had identified as part of placement reviews.

Do you use co-production approaches?

Our Trust is passionate about Quality Improvement and our team are involved in a QI project around the accommodation pathway. We have a service user representative as part of the project team.

Quality Improvement (QI) is a method applied to understanding and improving problems where the issue is not entirely understood or the solution known

It allows for clear formulation of goals for improvement, by breaking down components within current systems and testing change ideas to visually track their impact on the issue

In our placement review work, we often reflected on how stuck we got with proceeding with step down once it was identified and this led to the QI project. The team has run a project for the past 24 months – aiming to achieve 25% increased throughput within the MH funded accommodation pathway

Service user input has been a key part of this project. As well as throughput we wanted to improve the experience of placement reviews for service users. Our belief is that when people feel that their views are heard in placement reviews they will feel empowered to engage in any process of move-on and are more likely to take an active role in the process and have a positive experience. We have sought feedback on the placement review meeting itself and the process of moving.

We have seen the following results so far:

· 12.5% increase in appropriate move-ons achieved over 2 years

· Throughput and LBH spending maintained despite the loss of 50 HRS placements

· Improved partnership working with adult social care and general needs housing

· HRS provision and floating support contracts to re-tender- influencing commissioning and scoring bids

· Improved panel process with less presentations rejected for funding

· Placement review embedded within the team

· Improved and more robust processes

· Reduced paperwork for clinicians

· Positive feedback from service users and staff

We use Dialog+ as part of the CPA process with service-users with care coordinators. The scale includes the following:

•8 items –measure of subjective quality of life

•3 items – measure of treatment satisfaction

•Interpretation is straightforward

•Each item meaningful

•It is preferred by patients to other scales

•It is increasingly used as outcome measure

•It can be Interpreted for individual patients and services

Questions are set out as follows:

•“How satisfied are you with your…”

· mental health

· physical health

· job situation

· accommodation

· leisure activities

· partner/family

· friendships

· personal safety

· medication

· practical help received

· meetings

•Rating of each domain from 1-7

•‘Do you need more help in this area?’

Responses to Dialog+ help to ensure that the service user has an opportunity to raise issues that are important to them and this can be incorporated into recovery goals and support plans.

Do you share your work with others? If so, please tell us how.

We have submitted details about our service to NHS England via the ‘Getting It Right First Time’ Programme for Mental Health Rehabilitation. We have submitted information to the Royal College of Psychiatrists as an example of good community practice. Members of the team have also participated in NHS England Complex Care Transformation Programme/Rehab pathways forums and our Consultant Dr Ahmad recently attended an Mental Health event in Parliament – ‘Care not Containment’ hosted by the Right Honourable Normal Lamb looking at use of long stay inpatient beds and improving community mental health provision.

We are just starting to realise how different our approach to rehab is in comparison with other services and we are taking every opportunity to share our model through various networks. Our consultant has a Twitter account @sheraz_ahmad_ with the primary focus to talk about our rehab approach and to promote discussion and challenge some of the inertia around current services.

What outcome measures are collected, how do you use them and how do they demonstrate improvement?

As above, we use Dialog+ as part of the CPA process. We do not focus on symptoms but try to use a more recovery led approach trying to find where the important parts of the care plan are located for the patient and on their general wellbeing. This is measured more systematically via the ELFT DIALOG+ care plan and the measures and qualitative information involved.

The Dialog+ tool includes

•8 items – excellent measure of subjective quality of life

•3 items – good measure of treatment satisfaction

•Interpretation straightforward

•Each item meaningful

•Preferred by patients to other scales

•Increasingly used as outcome measure

•Interpretation for individual patients and services

•“How satisfied are you with your…”

· mental health

· physical health

· job situation

· accommodation

· leisure activities

· partner/family

· friendships

· personal safety

· medication

· practical help received

· meetings

•Rating of each domain from 1-7

•‘Do you need more help in this area?’

We have two occupational therapists who are Assessment of Motor and Process Skills (AMPS) trained – a standardised OT assessment. We use this most often within our Occupational Therapy led rehabilitation accommodation repeating assessments to monitor progress.

We use PREMS within our service and we incorporate comments into a ‘you said, we did’ programme to make changes to the way we run elements of the service. We use tablets to collect this data either in CPA meetings or patients can use a tablet in our reception area. Results are shared with the team in our monthly business meeting and ideas shared about how we can address any requests.

As described above we measure outcomes for the accommodation pathway through our QI project. We have seen the following results so far:

· 12.5% increase in appropriate move-ons achieved over 2 years

· Throughput and LBH spending maintained despite the loss of 50 HRS placements

· Improved partnership working with adult social care and general needs housing

· HRS provision and floating support contracts to re-tender- influencing commissioning and scoring bids

· Improved panel process with less presentations rejected for funding

· Placement review embedded within the team

· Improved and more robust processes

· Reduced paperwork for clinicians

· Positive feedback from service users and staff

Has your service been evaluated (by peer or academic review)?

Our Trust has been awarded an ‘Outstanding’ rating from the CQC.

How will you ensure that your service continues to deliver good mental health care?

Over the last 10 years of our team there has been a shift away from a care coordination caseload towards specialist placement review and resettlement and complex case management. This has led to a move from ad hoc reviews directed by accommodation managers to rehab team annually reviewing service-users in funded placements. We have recognised in this time that cases are becoming more complex and specialist skills and knowledge is often needed to facilitate move-on. The evolution of the team and development of this expertise alongside our ongoing work with our care-coordinated patient group means that we add value to the broader system. We are recognised as a specialist team and a team that can help with complex and challenging work and there is no indication that the demand for our input will decline.

In addition to this we receive funding from borough for our placement review work and from the City of London for our reablement work which helps to sustain our team over and above NHS funding.

In terms of the future for our service and some reflections on what we have learnt so far:

We are working with LBH commissioning and procurement to set up a framework of mental health supported accommodation providers

Potential development of new services, e.g. housing with care model with flexible age criteria, for adults with severe and enduring mental health difficulties. New provision for complex/high needs.

Do we need block-funded residential care? How could we use funding differently to continually evolve a supported accommodation pathway?

Continuing to develop reablement expertise

Continue to develop expertise in complex placement issues

Becoming experts in new models of housing & support (Housing First), new technology (tele-care options), personal health budgets

What aspects of your service would you share with people who want to learn from you?

We are passionate about developing our service and continuing to support people with complex needs to live within the community with appropriate support in place. We feel strongly that we should avoid long stay admissions if at all possible and promote independent living with access to the local community as the norm. We want people to recognise that there are different models of delivering rehab services and ours is a good example of this.

Through partnership working with other agencies we have created a strong network which has resulted in an integrated approach to delivering our community rehab service. This extends beyond our patients under care coordination to patients who we case manage. Part of this has been recognising how we fit into the wider system and developing expertise to compliment this and make a positive impact.

Commissioner and providers

City and Hackney CCG

London Borough of Hackney LA (LBH) Section 75 agreement

Provided by (e.g. name of NHS trust):

East London NHS Foundation Trust

Size of population and localities covered:

London Borough of Hackney – population 275,929

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City and Hackney Community Rehabilitation and Recovery Service – East London NHS Foundation Trust – HC – #MHAwards19

Co-Production

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