The Mental Health Liaison Team is a model of Liaison Psychiatry which is multidisciplinary with a single point of access available 24 hours a day and open to all patients with mental health and drug and alcohol problems presenting to acute care. The team covers people 16 years to end of life. Out of hours the team also covers CAMHS and peri-natal mental health.
Promoting integration of mental and physical health – the ethos of the team is care is shared with the Acute Health Trust. It is not about ‘our patients or your patients’. You will often hear in conversations between different teams people are being described as ‘our patients’ which shows care is integrated. The team has also worked on a number of initiatives to move the point of integrated forward by using mental health perspectives to understand a complex health system
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The Mental Health Liaison Team is a model of Liaison Psychiatry which is multidisciplinary with a single point of access available 24 hours a day and open to all patients with mental health and drug and alcohol problems presenting to acute care. The team covers people 16 years to end of life. Out of hours the team also covers CAMHS and peri-natal mental health. Mental disorder in an acute hospital is an independent predictor of poor outcome, increasing length of stay, decreasing capacity to return to independent living and increasing the reliance on family carers or the need for institutionalisation (RCPsych, 2005). Embedding specialist psychiatric and psychology expertise within the acute or general hospital team ensures appropriate identification, assessment and treatment of the mental disorder. The Service is based within an acute hospital and became operational in April 2014. It is now fully functioning and after its initial project status it secured recurrent funding from 2016. The team has developed a number of projects which is now fully embedded into established practice. The developments include – • A Service User led art project for the Emergency Department – ‘HopeWall’ • Schwartz Round – support for staff with a psychological perspective. This won trust recognition as support team of the year 2017. • Frequent Attenders/ High Intensity User team – fully commissioner with recurrent funding • Established training pathway with approx 1700 staff trained each year in mental health awareness and related topics. The philosophy of the service: Patients with mental health problems in the acute hospital setting should have equal and fair access to psychiatric assessment and treatment by appropriately skilled professional staff. The team is a full Multi-disciplinary team made up of nurses, doctors, psychologist, Occupational therapists, administrators and a volunteer. There is a senior leadership in the team with a mix of operational and clinical leadership responsibilities.
What makes your service stand out from others? Please provide an example of this.
Promoting integration of mental and physical health – the ethos of the team is care is shared with the Acute Health Trust. It is not about ‘our patients or your patients’. You will often hear in conversations between different teams people are being described as ‘our patients’ which shows care is integrated. The team has also worked on a number of initiatives to move the point of integrated forward by using mental health perspectives to understand a complex health system. Examples are o Established teaching for acute health colleagues – 1700 staff trained on year average a year in 81 sessions o The liaison team provides monthly supervision for colleagues from other teams o The team alongside the community mental health liaison team developed competencies for integrated working – the competencies have been included into the Vanguard site of ‘Tower Hamlets Together’. It has been further developed into ‘The Wheel of Partnership’ which guides the development of integrated care in Tower Hamlets o Developed a mental health triage model for A&E o Age inclusive- integrated liaison team specialist nurses/ consultants/ psychologists/ OT o Frequent Attenders/ High Intensity User twice monthly meetings with LAS, Police, learning disability, Drug & alcohol, ED and mental health staff. o Developed a screening tool for unmet mental health needs in a long stay population o Gastroenterology, diabetes and renal psychiatry – staff supporting medical specialties and run clinics alongside acute health colleagues o Joint working- Delirium and Dementia team, palliative care and other surgical & medical specialties- including our team staff providing supervision to other specialties o Introduced and developed Schwarz Round. o Support Barts health with their mental health related policies and procedures- such as development of enhanced care policy and training packages. – Service user involvement o Service user led on the development of the ‘Hopewall’ for the Emergency department. We worked together in identifying the artist, gather information to inform the art work and regular focus group with the artist. o Co-produced training package with service users and carers for the Crisis Mental Health training o Service users are involved in recruitment of all staff o Service users co-produce leaflets and letter templates
How do you ensure an effective, safe, compassionate and sustainable workforce?
– The team has low staff turn-over and most staff has been in the team more than four years. – The sickness rate in the team is 3.44% which we think indicates an engaged and hopefully healthy team. – Regular away days to look at team development and staff support. We have three away days a year – Monthly supervision for staff (trainees more frequently) – all non-medical staff are supervised by the two lead nurses. – Yearly personal development plans with a 6 month review of progress. – Manager and senior staff has a ‘open door’ policy to discuss concerns – Culture in the team of shared care and reflecting/ discussing care is encouraged. It is written into the operational policy that staff are expected to use the wider team to discuss patient care to ensure the best outcome for the person and as a way of managing staff anxiety. – Weekly clinical meetings and daily hand-over meetings – The service is expanding and we are partnering with new organisations to develop their mental health liaison provision. – The team leads on providing a mental health liaison course at City University. The course is based on the mental health liaison nurse competencies and aims to upskill all staff in liaison care. The course is run at BSc/ MSc level. – Development plans includes shadowing between staff members – this acknowledges each person’s skills and expertise
Who is in your team?
The team consists of: – 1 wte Service Manager band 8B – 1 wte Nurse Consultant Band 8B – 1 wte Clinical Psychologist Band 8B – 1 wte Occupational Therapist Band 7 – 2.8 wte Administrators band 4 & 5 – 11 wte Senior Liaison Mental Health Nurse Practitioners Band 7 – 2 wte Liaison Mental Health Nurse Practitioners band 6 – 4.5 wte Consultant Psychiatrists – 2* wte Senior Registrars – 1*0.2 GP – Junior Doctors – GP Trainees – 1 wte Assistant Psychologist – Volunteer
How do you work with the wider system?
– We have integrated ward rounds with other teams- eg. Delirium and Dementia teams attends our clinical meetings and we attend theirs. . – Monthly Integrated clinical governance meetings with the emergency department – Developed framework for managing the 1:1 support for Barts Health NHS trust including a training package for staff delivering enhanced care – Shared protocol for transfer and physical fitness between mental health and acute trusts – The liaison team manages incidents for Barts- shared governance agreement between mental health and acute trust. – Frequent attenders – information sharing agreement between GP consortium, acute trust and mental health trust. The group work under the Caldecott Principles of sharing care for highly complex and vulnerable people. – Frequent Attenders Core group – LAS, Police, Drug & Alcohol, Learning Disability, Emergency department and mental health liaison. GPs are involved in all cases and new funding includes a part GP to work on the team. – Discharge forum attendance where there is a reflection on what worked and didn’t in different cases. – Monthly ‘MADE meetings’ – the mental health liaison team is part of problem solving to find solution to help people being discharged. – Work closely with Age Uk, Homeless pathway, Alzheimer’s Society, drug and alcohol teams – Teaching averaging 1700 allied health professionals – we also teach community colleagues on integrated care and mental health in a liaison setting – Lead on training for the competencies for liaison staff at City University London – Local authority regular safeguarding strategy meetings – All new starters in A&E shadow our mental health team- we are one of Key Partners in A&E and have input into all inductions
Do you use co-production approaches?
Service user involvement o Service user led on the development of the ‘Hopewall’ for the Emergency department. We worked together in identifying the artist, gather information to inform the art work and regular focus group with the artist. o Co-produced training package with service users and carers for the Crisis Mental Health training o Service users are involved in recruitment of all staff o Service users co-produce leaflets and letter templates • We routinely seek opportunities for co-production with experts by experience. We have experts by experience on our recruitment panels to help select patient focused staff. • We have adapted numerous approaches to gather service user feedback through postal questionnaires, online questionnaires with access via electronic tablet on wards and a volunteer who telephones patients for feedback. • We have recently completed a project to improve the space of our assessment room in A&E. Through co-production a mural ‘the Hope wall’ was designed by a local artist and experts by experience. • Our most recent QI project which we have begun will look at factors influence length of stay and re-admission rates in the hospital. This will be co-produced with experts by experience. • Promotional leaflets and letter templates are developed with local service user groups to ensure language is appropriate and the information is useful/ helpful.
Do you share your work with others? If so, please tell us how.
The team regularly presents at conferences including – Cognitive Impairment in an Acute setting (Psychiatric Liaison Accreditation Network PLAN), Providing Alternatives to A&E (PLAN), Supporting a Frequent Attender (PLAN), Supporting a Frequent Attender in a Mental health Crisis(Positive Practice in Mental Health), Evaluation of outcome of Mental Health Awareness teaching (MHNAUK conference). – The team developed an on-line mental health awareness package for Barts health Staff. This is now included in their mandatory training package. It is for all staff – clinical and non-clinical. – We host visitors from different trusts – recently hosted the Northern Ireland Health Board who were looking for examples of liaison practice. – Published textbook on liaison mental health nursing – We won funding for and ran a Self-help materials project for people attending or admitted to the acute hospital – Teaching at local recovery college on Crisis Mental Health Care – Arranged a trust Crisis Conference with NHS England speakers and Serious Incident Learning workshops. – Teaching- disseminating learning and experience including sharing a service evaluation of the outcomes of Mental health Awareness training for all new nurses to the trust. – Staff in the liaison service are on several RCPSych faculties including neuropsychiatry and liaison. Staff also sits on the Special Interest group in the RCN. This enables input and guidance on policy and funding. – Regularly asked to comments on expert panels to support NHS England developments such as CQUINS and ‘Blue Light’ protocols.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The data collected is used to monitor referrals to each part of the service, monitor trends in referrals, monitor Emergency Department breaches, monitor reductions in bed days. We are measured on – o Average wait to be seen in A&E – target is 95% and we are currently 90% o Average wait to be seen on the ward – target is 95% and we are 98% o Occupied Bed Days (OBD) for high risk patients (dementia, depression and SMI) – we are consistently meeting the targets and are performing 12 months below target of close to 2 days reduced OBD. The team developed a mental health triage pathway to improve the urgency the patients are being seen. Data is collected from a variety of sources: o Emergency Care Data Set – part of developing national evidence for the emergency mental health needs. o RiO – the mental health clinical system, o CRS – the acute hospital clinical system, o A book with manual recordings of patients who are seen by the mental health liaison team in the Emergency Department – this helps us with oversight of who has been in contact with the team and monitoring their outcome measures o All clinical contacts are recorded on CRS and RiO clinical systems PREMS: o The admin staff in the team use a tablet preloaded with questions from which the patient selects the answers depending on their experience of care. They collect feed-back from patients admitted to the ward. o There is a volunteer who collects feedback from people who attended the Emergency Department in a mental health crisis. This is done over the phone after they presented to A&E. CROMS: o All people discharged from the team have a Clinical Global Impression Scale done for their contact. We are asking other teams and organisations for feed-back on the support from the Frequent Attenders team to ensure the work is helpful to the wider health system. Outcome Measures and how it has been used for improvements – o Development of a mental health triage pathway o Changes to transport contracts to ensure there are less delay in discharges o Agreement on pathways to in-patient beds between in-patient mental health wards and acute hospital o Identification of wards where less referrals are generated and therefore a focus on attending ward and supporting more.
Has your service been evaluated (by peer or academic review)?
The Service is Royal College of Psychiatry Psychiatric Liaison Accreditation Network (PLAN) accredited until January 2020. It’s the 3rd time it has achieved accreditation. – CQC inspection 2018 for Barts Health NHS Trust where the Tower Hamlets Mental Health Liaison Team was inspected – crisis and emergency seen was assessed as very strong service – CCG staff has spent clinical shifts with team and reported on their observations – The RAID project which became the Tower Hamlets Mental Health Liaison Team was evaluated by UCLP for its outcome.
How will you ensure that your service continues to deliver good mental health care?
The team is involved with research on different levels – – Partnering with Manchester University on their MHapt study which is a longitudinal study on development of support. This is with NiHR funding – Partnering with City University London on the ASSuRED research project. This is NiHR funded project. – Consultant psychiatrist is part time researcher in Queen Mary’s University and leads on a Non-epileptic Attack Disorder study. – Application for funding in Frequent Attenders jointly with City University London has been submitted to NiHR and Barts Charity – QI project looking at reducing length of stay for a long stay population in an acute hospital
What aspects of your service would you share with people who want to learn from you?
We have worked alongside Commissioners since the formulation of the service began in 2013. There are regular meetings, including quality meetings, with the Commissioners which build strong links and understanding of the work and progress being maintained and achieved. The service has secured permanent funding since the initial 2 year project was successful in March 2016. The yearly appraisal and personal development plan includes planning for succession. Staff are encouraged to develop leadership skills. The majority of staff have attending QI training as part of the Institute for Healthcare Improvement programs run by East London Foundation Trust. Policies, processes and ‘how to guides’ are all saved in a shared drive so staff have access to information. Audits, outcome measures and reports are also saved in the shared drive. Staff are all given responsibility for different part of the service as succession planning. – Individual staff improvements in managing a service – Promoting strong leadership abilities in senior staff
How many people do you see?
The Team had 7235 referrals from April 2018- March 2019 which were all accepted – The total number does not include multiple contacts and interventions. The Frequent Attenders team as support 148 people over the last 3 years
How do people access the service?
– People can self-refer via A&E – Patient can request referral to the service when admitted – Referrals comes predominantly from professionals – All people seen in A&E are given a care plan with contact details. – We are a recognised part of the mental health crisis care pathway – All referrals are reviewed by the team and delegated to the person who is best suited to meet the need for the presenting concern. All staff have been trained in providing a baseline assessment via the biopsychosocial assessment. The team also provides the section 136 provision for Tower Hamlets but does not have a dedicated section 136 suite. The A&E department has a Health Based Place of Safety.
How long do people wait to start receiving care?
Average wait to be seen in A&E within 1 hour – target is 95% and we are currently seeing 90% of patients within 1 hour o Average wait to be seen on the ward within 24 hours – target is 95% and we are currently seeing 98% of patients within 24 hours
How do you ensure you provide timely access?
– A mental health triage process has been developed for A&E to make sure people are seen sooner in the A&E attendance process. – The priority is done using a risk stratification – the team looks at urgency of referral, presenting problem and what level of the support the person has i.e. a person at risk of suicide in A&E will be seen before a person on a ward who has a whole ward team for support who may have cognitive impairment. However, all will be seen. – The team is able to mobilise across the different parts of the team so if there is higher level of referrals in one part other parts of the team will support. The team has minimal 2 nurses on each shift with a junior doctor, senior trainee and consultant on shift. Out of hours the consultant is on-call. There is management cover on all days and out-of hours this cover is done via an on-call rota.
What is your service doing to identify mental health inequalities that exist in your local area?
The team collects data for part of the Emergency Care Data set to help inform NHSE on what the mental health care needs are. The Key Performance Indicators collected locally feeds into the Urgent Care Board and informs on the local needs. The Frequent Attending audits has informed the local Tower Hamlets Together Board (a partnership between GP consortium, mental health trust, acute health trust and social services) on development of integrated care. – We provide anti-stigma training to staff including all new starters at the Royal London Hospital and development pathways for Barts Health NHS Trust. – We lead on the Frequent Attending work which is support for a highly stigmatised group of patients. Our approach is to ensure right care for people who are often vulnerable and not receiving care through ususal means due to a number of factors such as reduced engagement. – We try and apply a mental health perspective to all physical health settings – The ‘Hope wall’ art work was developed to make the mental health assessment room appear less oppressive and more of an inviting space. The thinking was it would not only benefit the person being in a mental health crisis but it would also communicate something to staff working in A&E – that there is hope in mental health.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
We work with a large group of people from the Bangladeshi and Pakistani community who would traditionally not recognise mental health issues such as dementia. The group of people often does not seek help for cognitive problems. As they are in hospital it is a good opportunity to discuss and assess the difficulties a person may have. As the group is difficult to reach the diagnosis is completed in hospital. – We work with people with Alcohol Related Brain Disorders and formulate a diagnosis of dementia. This group of people often struggle with attending appointments and by doing this in the general setting we are able to ensure they get an appropriate care package and support. – We use our mental health perspective to help the wider system understand the struggles people have in engaging in care. We help the system develop personalised care plans to enhance people’s engagement in their care.
What is your service doing to address and advance equality?
The team use the biopsychosocial assessment to ensure all aspects of a person’s needs is being used. The assessment includes social, psychological/ psychiatric and social issues. – The team ask the question if a person is having a failed discharge ‘why is it the care is not working if it in principle should’. This helps us understand the drivers behind why care plans are not working. – The team has developed a screening tool for identifying unmet mental health needs in a long stay population.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
The team use the biopsychosocial assessment to ensure all aspects of a person’s needs is being used. The assessment includes social, psychological/ psychiatric and social issues. – The ask the question if a person is having a failed discharge ‘why is it the care is not working if it in principle should’. This helps us understand the drivers behind why care plans are not working. – The team has developed a screening tool for identifying unmet mental health needs in a long stay population. – The team uses screening tools such as RUDAS, ACE III, Connell Depressions Scale, MOCA, PHQ9, GAD 7, Traumatic Brain Injury Scale, BAMSE – The team uses tools which are adapted for cultural differences such as RUDAS and BAMSE – Functional assessments by colleagues to help inform the team on how any mental health or social difficult impacts on the person’s ability to function. – Joint assessment with social care teams – Joint assessments with specialty teams for complex capacity assessments.
How do you meet the needs of people using the service and how could you improve on this?
The work the team delivers is effective as evidenced by the sustained reduction in occupied bed days over 12 months, reduction in A&E attendances by Frequent Attenders, reduced length of stay for frequent attenders and reduced total admissions by frequent attenders. The qualitative feed-back as collected as part of the PROMS are overall positive. However, the team is also aware about negative experiences and each report or complaint is used to look at how the work can be improved. One such example is training for staff on ‘confidentiality and working with carers’ following a complaint made by a relative.
What support do you offer families and carers? (where family/carers are not the service users)
The team speaks to carers for collateral information to help understand what the person’s strength are and how any challenges may be affecting them. As part of this conversation the carers are offered advice on local support groups such as Alzheimer’s Society, MIND, Rethink carers Centre. The team are also developing a model of care with the acute trust on ensuring the right collateral information is collected early in the admission. The idea is by having a more thorough collateral history from the beginning the team will be able to help the care system get the right care for the person sooner. This work is being done as a QI project and aims to upskill all staff in asking the right questions to tease out if there is unmet social/ physical or psychological needs. The team teachers Crisis Mental Health Care at the local Recovery College and the course is attended by Carers as well as service users and professional staff. The training is co-produced by service users.
Have you implemented any of the mental health care pathways developed by the NCCMH (on behalf of NHS England)?
Liaison Mental Health Services for Adults and Older Adults
Emergency Mental Health Care
If you have implemented any of the above, what were the benefits and challenges?
The main benefit is working with an acute trust who sees the value of having mental health embedded into their services has helped develop the service the way it is over the past 5 years. – The key is to be very clear from the beginning of what your shared goal is as a team. The team had many Key Performance Indicators and views by the acute trust of what they wanted. The team took into account all the main stake holders views and interpreted this from the perspective of what we knew our service users (who are the most important stake holders) wanted which is he best and most timely care. This became our focus. – The stigma of mental health is still prevalent in society and the team wanted to ensure people who are at risk of being stigmatised against get the right care. By having a clear patient centred ethos it guides the team in the care we deliver. Any conversation starts from the perspective of making sure the right thing is done by the patient. It helps engage staff from other services and perspectives when good patient care is the focus. – The team worked on influencing stigma by ensuring all staff are collaborative with the acute trust. This ensures the team is not being perceived as ‘difficult’ which in turn improves the perception of the people we are trying to support. Patients are not waiting for medical clearance – instead people are seen concurrently which means mental and physical care happens alongside each other. – Get to know the people in the organisation who can help further your goal of good patient care. Understanding who the allies is important – Get to know key partners in trust and develop a shared understanding of what they want to achieve.
Commissioners and Providers
Commissioned by : Tower Hamlets CCG
Provided by (e.g. name of NHS trust) or your organisation: East London Foundation NHS Trust
Brief description of population (e.g. urban, age, socioeconomic status):
The team covers an inner city hospital in London with an Emergency Department, 845 medical & surgical beds, major trauma centre and a number of national medical specialties such as regional neuroscience centre and a tertiary trauma centre. It’s a busy hospital based in the East End in an area with a number of inequalities. Tower Hamlets is the poorest borough in the country and has a high level of ethnic diversity. It has double the national rate of child poverty. The Health in the borough is characterised with lower life expectancy and higher death rates of conditions which are perceived as preventable. There is above average issue of smoking, drinking and substance misuse. HIV, sexually transmitted disease and tuberculosis is also above national levels but also in contrast the borough has high levels of testing and detection. The prevalence of severe mental illness is above the national average. The air quality in Tower Hamlets is very poor compared to other London boroughs. The hospital covers a diverse group of needs and as well as caring for the local population it also provides are for people from other parts of the country. Audits shows approximately 25% of referrals to the mental health team in the Emergency Department are from out of area.
Size of population and localities covered: There are 308,000 residents in Tower Hamlets. The trauma centre covers North East London and Essex which makes the total population larger. The hospital is situated near a number of transport hubs wich means people travel from different parts of the country and arrive in A&E if they have acute mental health needs. The mental health liaison team sees – – A&E – on average 320 referrals a month – Wards – on average 250 a month
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