The Older People's Mental Health Community Social Work Practice coordinates the provision of information and advice to older people and their carers who are also being supported by secondary mental health services about the care and support options available to them, and what might produce the best outcomes for them.
What We Did
The Older People’s Mental Health Community Social Work Practice coordinates the provision of information and advice to older people and their carers who are also being supported by secondary mental health services about the care and support options available to them, and what might produce the best outcomes for them. The team of 5 qualified social workers (1 Commissioning Manager, 1 Advanced Practitioner and 3 Social Workers) help people to reconnect with their communities and their families to ensure that they play a valued part in society and are afforded the social norms which will lead to them being provided with a platform to regain independence, live a meaningful life with reduced state control and be able to ascertain the best possible outcomes for themselves and their families and carers. The team work in partnership with the person as part of their recovery journey to ensure a proportionate response to expressed need and where ever possible avoid an unnecessary admission to 24 hour care.
The team was established in April 2015 in response to increasing concerns about over reliance on the part on the existing mental health services for traditional social care services which placed restrictions on people’s liberty such as care homes. In the 2 years prior to the team being established there had been a 12% year on year increase in the number of older people who were being placed into care homes. This compared with a 20% reduction in the number of placements into care for older people who did not have involvement from secondary mental health services.
The team made an immediate positive impact seeing an 80% reduction in care home placements from an average of 8.2 per quarter to 1.8. Social Care Quality of Life has increased in the same time period on the annual service user satisfaction returns from 19 to 21.
Maureen and Frank (names have been changed) have given permission for their story to be published which illustrates the approach the team take: Maureen was admitted to hospital following a fall and was becoming confused due to her advancing dementia. Her husband, Frank, was struggling to cope with his role as carer and was finding it increasingly difficult to meet her needs as she was increasingly frail.
Frank was advised by his GP to make contact with the Older People’s Mental Health Community Social Work Practice to get help as Maureen returned home from hospital and to request an emergency respite admission into 24 hour care. The social worker arranged for the Calderdale Urgent Home Support Service to provide intensive home support for Maureen and Frank in the first 48 hours after discharge from hospital. They also arranged for a door exit telecare sensor to be fitted and for Maureen to be provided with a falls monitor.
Frank was supported to completed a carers assessment and agreed a carers emergency back-up plan with details of emergency contacts and contingencies for Maureen in the event that he became unwell. Frank was also connected into a carers support group through Alzheimer’s Society where he could talk to other people in similar circumstances. Maureen and Frank were supported to join the Daffodil Cafe in their local town where they found that Maureen enjoyed art and singing. Maureen joined the Singing for the Brain group.
These interventions avoided Maureen having to be placed into 24-hour care and kept both Maureen and Frank living together in their own home
Wider Active Support
The team work very closely with Cloverleaf Advocacy to ensure that people have access to an Independent Mental Health Advocate, Independent Mental Capacity Advocate or Care Act Advocate where there is evidence that the person has substantial difficulty in understanding the health and social care system and needs support. They also work very closely in partnership with the Community Mental Health clinical team within South West Yorkshire Partnership Foundation Trust and on the Dales in Halifax.
The approach towards coordinated care with colleagues from the Mental Health Trust is to ensure a consistent approach to enable people to encourage recovery and optimise neuro-rehab through supporting positive risks. The Service have tested out operating a Risk Enablement Panel which is fully accessible to staff and users at various points of their pathway. The Panel is convened only when there are complex risks identified during the normal process of signing off an individual’s Support Plan, which cannot be resolved through the usual channels of decision making within the relevant team, and where there is a clear difference in opinion relating to the proposed Support Plan.
The Risk Enablement Panel provides a forum for full and frank discussion and resolution of perceived serious concerns relating to the management of identified risks highlighted in an individual’s Support Plan.
The Community Social Work Practice also make great use of voluntary and community resources, the specifications for which they have informed so that services are continually being reviewed and improved to meet presenting need. These include the Calderdale Urgent Home Support Service which was commissioned to provide emergency home based support on a shared care basis with the more specialist nursing crisis intervention team to increase the number of people who could be stabilized and assessed in their own home.
The major impact of the team has been in the rapid expansion over the last 18 months of the Alzheimer’s Society local offer. From just 2 Daffodil cafe’s a month for the Borough, there are now 8 cafes running across the Borough, 4 carer support groups and 2 signing for the brain groups.
The Alzheimer’s Society have been commissioned to coordinate peer and carer support networks to drive service improvement and feedback to staff on how the service is operating. 400 people with dementia and 200 carers have been made contact with and connected into the network which the Alzheimer’s Society are setting up around the Community Social Work Practice. Quarterly evaluation reports are given to commissioners on how the service and the dementia friendly borough work in Calderdale is progressing from the perspective of people who are recieving support.
Annually a satisfaction survey using the Social Care Related Quality of Life composite measure is collected and reported on. Each social work intervention is evaluated and critically reflected on.
Looking Back/Challenges Faced
We would have taken more time to work with the Mental Health Trust to understand the case for change and work with us on moving positively forwards together. This would have avoided some challenges listed below. We have learnt from this and are currently working in a very coordinated was to review working age adults social work as an Early Adopter of the Social Work for Better Mental Health resources published by the Department of Health and supported by the Chief Social Worker for England (Adults).
There is significant learning emerging from this work which we are building into our Transforming Care Programme as part of local Sustainability and Transformation Plans.
The team has delivered a significant financial saving (in the region of an estimated £1M per annum) through preventing avoidable care home placements. The longer term savings are yet to be calculated, but given the number of people who have been identified and connected in peer and carers support numbers it is anticipated that further significant savings are accruing.
Sustainability is being built in through the Older People’s Mental Health team being aligned with the wider Community Social Work Practice. Team members from the wider practice are given carefully selected case work to enable them to build experience within the mental health client group and health services.
We are also in discussion with Think Ahead and planning to attend the summer school at York this year with a view to becoming a full partner for 2017 intake – the cohort “”pod”” would be aligned to this team to further build resilience and expand its reach across working age adults mental health practice.
The LGA conducted a National Peer Review of our social work practice including this team in January 2016. The feedback from the Commissioning for Better Outcomes Review was that: social work values are strongly applied and upheld; the supported living and community accommodation offer was valued by people living there and their carers; the vision for commissioning and strong social work values provided for a positive framework for the future.
We share through the following networks which we are a part of: 1 of 7 Local Authorities to be early adopters of the Social Work for Better Mental Health Department of Health pilot; Think Local Act Personal – Member of the commission for Individual Service Funds to support diversification of the range of flexible support contracting methods to enable people who lack the mental capacity to manage their own arrangements to exercise maximum control over their support to remain at home; member of the Calderdale Mental Health Innovation Hub – monthly forum to coordinate and share best practice and develop new approaches; member of the Adult Principal Social Worker Regional and National Networks sharing practice ideals; we are presenting our innovation work in mental health and learning disabilities at the Regional Yorkshire & Humber ADASS Summer Conference in 2016.