The Rapid Intervention and Treatment team was established to provide an older adult mental health community service that concentrates on maintaining people in their own homes or care home, avoiding hospital admission, providing a same day response to those presenting in crisis and is able to provide up to four daily visits, as well as supporting people in hospital to experience a safe and timely discharge. The team promotes the use of non-pharmacological and psychoeducational interventions with a multi-disciplinary approach, utilising pharmacology where needed, maintaining a recovery focus throughout.
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
The Rapid Intervention and Treatment team was established to provide an older adult mental health community service that concentrates on maintaining people in their own homes or care home, avoiding hospital admission, providing a same day response to those presenting in crisis and is able to provide up to four daily visits, as well as supporting people in hospital to experience a safe and timely discharge. The team promotes the use of non-pharmacological and psychoeducational interventions with a multi-disciplinary approach, utilising pharmacology where needed, maintaining a recovery focus throughout. Prior to the establishment of the team, there was no or little alternative to hospital admission, with the only available service being the older adult community mental health team offering a 9-5 Monday –Friday service. The team has enabled people to remain in their own homes, providing better outcomes and enriching the patient experience and improving of lives for those they care for.
What makes your service stand out from others? Please provide an example of this.
In addition to providing crisis intervention to both people living in their own homes and care homes, the team provides a unique in- reach service to the local Acute Trust and the surrounding community hospitals. This arm of the service enables workers to provide timely assessments and mental health expertise, into complex care presentations. This allows the team to support timely discharge, to the least restrictive environments, that meets the needs of the patient and their carers, promoting home as the preferred choice.
Below is feedback from the Community Coordinator, from the Acute Trust, which demonstrates how the service is making a difference. “I would just like to take a moment to email you with regards to the role of the in-reach practitioners. They have certainly been very patient focussed and been apparent on the wards in aiding and supporting a safe, personal and effective discharge, they contact the wards asking how the patient is getting along from when they have seen the patient earlier and keep the wards up to date with what is in place or awaiting and advise further should situations change for the patient. They will re-review patients on wards that they feel are at risk and also whether improvement has been made. What I also found to be impressive is that the same team also go to review patients at their discharged destination for follow-up! How good is that! Their approach to patients and staff on the wards is that of a perfect personality, I myself and other members of staff have approached and had a good chat about the patients and their advice and support has been second to none. They assist us in highlighting the patients that no longer need further input and also highlight those that still need further input. They communicate well on the wards with all members of staff and make their presence well known, which you do not often see from similar services, which is very refreshing and I feel some acknowledgement needs to be made on their fabulous work and efforts in putting patients first with such a caring, empathetic nature. I and the staff would like to see this service continue, it has made such an improvement out on the wards and facilitated earlier discharges, and I can confirm it has made a positive impact and it has been great doing some collaborative working. Well done to your mental health practitioners!”
Also, in April 2018 as part of the Pennine Integrated Partnership the team developed a Mental Health/Integrated Neighbourhood Action Plan. The plan detailed how the team would support integration with physical health services, across the 12 Pennine Lancs Neighbourhoods, each neighbourhood being based around a population of 30-50 thousand people Practitioners volunteered to represent the RITT at the Integrated Neighbour Team (INT) meetings. It was agreed that initially they would attend the weekly multi- disciplinary meetings held in four locations across Blackburn with Darwen, to offer feedback and support to their physical health colleagues. Working in collaboration with the Integration leads from the local authority and Wellbeing Network, the Service Manager, and the team manager, supported the attendance at the meetings, rolling it out across the East Lancashire Neighbourhoods. Feedback received from the Neighbourhoods described how having mental health practitioners attending the meetings had developed their understanding of the impact of mental health on physical health, how to provide timely intervention and knowing who to contact in a crisis.
The INT meetings also provide the opportunity for joint, holistic working across services, to enable service users to have access to consistent and bespoke care. Below is feedback from the North Neighbour INT Community Coordinator, regarding our mental health practitioner. “Just to let you know that the mental health practitioners currently attends North INT weekly, and for the past two weeks has been able to base herself within District Nurse Office. She is an asset to the INT, her advice/ guidance feedback and general discussion is greatly appreciated. I will write up how she influenced actions for a patient, who was not a mental health patient and the outcome was positive improvement.” In addition below is feedback from the Burney Neighbour INT community coordinator. “I wish to give you some feedback regarding the RITT Team and the value of what they do within the neighbourhood team. We are the Burnley East and West Integrated Neighbourhood Team and I can speak for both team meetings that they are a necessary and vital part of our meetings due to the work they are doing or have done with the patients we have discussed.
As there are many multi-professionals sat around the table including GP’s and a Geriatrician Consultant the information gathered is key to how treat and take action plans forward with those professionals around the table. I can feedback from the East meeting were the practitioner has not only been able to share information but give advice and guidance to many professionals. The Neighbourhood working is going from strength to strength and we hope that representation can continue at these monthly meeting to benefit both the patient carers/families and those who continue to provide wrap around approach to their care in the community. Thank You for your continuing support within the Neighbourhood setting.” Following a review of the Action plan, within a discussion group, it was agreed to consider co-location of the mental health practitioner, within the neighbourhoods on the day of the meetings. This has now been actioned and the feedback above shows the positive impact of this and demonstrates how we are moving the integration forward.
How do you ensure an effective, safe, compassionate and sustainable workforce?
Establishing the RITT has not been without its challenges; staff had to relocate to different teams and areas. Team members brought with them their own culture and ways of working, which then had to be integrated within the cultures and ways of working of their colleagues. The team had to do this whilst covering a wider geographical area, which including a wider diversity of service users. A training programme was designed to ensure staff felt they had the right skills to cover all aspects of RITT from crisis interventions to educational support and non-pharmacological interventions within care homes. The team continues to be supported to access in house and external training courses to ensure a continued professional development within their developing roles. Team’s developed the role of a well-being champion who lead on a number of initiatives such as work place walks, team building exercises and social activities. This continues on a week by week, month by month basis, with new and creative initiatives coming up regularly- the most popular initiative being ‘woof Wednesdays’ in which staff can bring their dogs into work.
This was endorsed by the chief executive and the team have been inundated with requests from other teams, about how they might start this within their service. Each member of the team receives clinical and professional supervision as well as an appraisal and there is an open offer of coaching for all team members. Clinical supervision groups have also been established for all clinical staff to ensure staff have a safe space to share practice and learn from each other. Best practice groups were established in order to share best practice and encourage standardisation of approach (with local variation). The teams show amazing levels of compassion both for patients and for each other. The teams work with experts by experience in order to improve and develop the service. The teams actively produce ‘you said we did’ statements following patient feedback to highlight the importance placed on listening to the communities they serve.
Who is in your team?
1 Band 7 team manager 1 WTE 1 8A clinical psychologist 0.7 WTE 1 Band 7 Occupational Therapist (OT) 1WTE 17 Band 6 Mental Health Practitioners 17.6 WTE 2 Band 6 OT 1.8 WTE 1 Band 4 Assistant Practitioner 1 WTE 1 Band 4 OT Technical Instructor 1 WTE 3 Band 3 Health Care Assistants 3WTE 2 Band 3 Administrators 2 WTE 1 Band 2 Administrator 1 WTE 1 WTE Consultant Psychiatrist 2 Staff Grade Speciality Doctors 2 WTE
How do you work with the wider system?
The service generally requires all aspects of health and social care to work in partnership. The team are required to work with the local authority to review placements in local homes or to review packages of care to people within their own homes. The aim is to preserve residency in their own homes, or current placement to reduce the disruption to the patient, as much as possible. The RITT also provide a monthly clinic to a select number of care homes, across the locality, which aims to educate and upskill care home staff to meet the needs of their patients, before it reaches the need to involve secondary care mental health services.
RITT also work with primary care services supporting and advising on stepping up or stepping down the care of patients between primary and secondary care services, to ensure that patients get the best care possible for their current needs. In April 2018, as part of the Pennine Integrated Partnership, members of the RITT were united with physical health colleagues to form an action plan for supporting integration between physical and mental health services. This partnership is a key role in the emerging neighbourhood team. Following a number of joint workshops between primary care and RITT, it was agreed that a Mental Health Practitioner would be a key member of the weekly MDT meetings; their role is to advise, signpost and support patients with long term conditions and mental health crises. Building on their initial attendance, the RITT staff are now co-located on the day of the meetings, within the primary care setting. In October 2018 the team were approached by the CCG to develop an in-reach services to the Acute Trust. The aim being to support patients, on medical wards with mental health presentations, to be discharged home in a timely but safe manner; providing the least restrictive alternative care option possible. In addition the role acknowledged the need to support the Acute Trust with the additional winter pressures.
Following a period of initial success and positive feedback received from key partners, the role has continued to be funded by the CCG. Please feedback from the Team Manager of the Acute Discharge Team within Adult Social Care: “The RITT Team is an invaluable team that provides key complimentary mental health support to services users who may also have social care needs. Working more closely between social care and mental health teams (RITT) is essential and I hope that at the review, further integrated working relations between RITT and social care will be considered accordingly.” Also, feedback from the Senior Integrated Case Management Lead from the Integrated Care Group: “I am sure you can agree that the support provided as In-reach from the RITT Team for Mental Health Support and Recommendations has been invaluable to patients, families and staff throughout the Peripheral Sites. The support service has reached a point of Review and please could I make an URGENT request to those who wish to compliment the service provided by emailing any comments onwards.”
Do you use co-production approaches?
Co-production for this service is paramount as they acknowledge that patients and carers are the experts in their own life. The team listen to and use feedback from the friends and family questionnaires, when considering how to move services forwards. Compliments are shared within team meetings to boost morale and share positive practise examples. An example can be seen below: “The team member was described by the family member as “White Knight” and to quote “You kept dad at the heart of all your efforts demonstrating that despite his frailty his life counts too. You have given him back to us and we are thankful to you because we love him very much.” “You did not face an easy task in dealing with dad’s situation since you were effectively shining a light into areas where others had failed in their duty to care”” More specifically, the team have held a listening events for Carers of Service users with early onset dementia- providing afternoon tea for both service users to facilitate carers to attend their own events. The aim is to listen to and use the carer’s experiences with services to develop and evolve service support for the future. We have also held another listening event, alongside the patient experience manager, to understand the impact of bed shortages on those services users with dementia waiting for inpatient beds. The event also heard from carers of those service users too. Following this we identified the need to intensify support for services users, particularly those living on their own, but also for carers during this ‘waiting period’. The team are committed to and continual consider how co-production can be used in the future. One idea will be to consider how service users could be involved in the co-production of groups run within the RITT.
Do you share your work with others? If so, please tell us how.
The work of the RITT has been shared in a number of different forums; generally the team share practice within trust best practice groups and are open to visits from other Trusts. They have recently welcomed a visit from a neighbouring team who currently have no crisis support for older people, but were looking to set up a service in their locality. In 2018 the team presented at the Trust Quality Improvement Event sharing their experience of their care home clinic; new data will be presented at the same event in 2019 in the form of a research poster. The team have also shared their learning in the form of presentations at the following events: • Yorkshire and Humber Older People’s Clinical Mental Health Network meeting • The local Carer’s Forum • The Sheffield Special Interest Group for Positive Practice • The Self-Neglect Framework Launch Event All team also share their learning/experiences within their team based meetings too.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The team uses the Trust wide approved outcome measures documents to guide their individual practice and personal gains of service users. This document was developed in collaboration with a number of different professionals, and involved researching and reviewing a number of different individual measures that are used to assess severity and changes of individual mental health presentations e.g. anxiety, depression, etc and also behaviours that challenge within dementia. These are used at the start of involvement with the services and are then repeated at the end of interventions to assess change over time. This guidance document is currently under review by the network psychologists to ensure that the advice being offered is up to date. The evaluation of the input offered into care homes has been assessed using a specifically developed questionnaire. This questionnaire is presented before and after the clinic and is used to assess level of knowledge and confidence of the staff in managing the behaviours being discussed in the clinic. The latest review found that 100% of the care homes involved in the clinic reported that they felt RITT helped them understand their patients better. 74% reported that RITT benefitted all of their residents within the home because of increased knowledge and confidence within the staff. The team also uses the trust friends and family questionnaires and feedback questionnaires to be able to offer services users more opportunity to feedback on how the team had helped them to recover. The team recognises that formal outcome measures cannot always capture all the work they do and how this has helped improve the lives of services users.
The feedback is used to help capture the subtle improvements made. Please see below some examples of feedback offered to the team: “Thank you for the wonderful support which you gave me. I appreciate the fact that you were available every day and at any time, and your visits made me feel like I wasn’t struggling alone and that you really care. I cannot thank you enough.” “I was in a deep pit with suicidal thoughts and I did not want to live. The RITT was contacted and within 3 months I have begun to live life again. I was desperate for help and that help came from the RITT. Each visit was a source of comfort and help by which I gained confidence to accept the circumstances. I can honestly say thanks to the whole RITT team. I am a better person with a greater respect for other people and a much better understanding of life.”
Has your service been evaluated (by peer or academic review)?
The team supported the research “Understanding crisis team working with semi-structured interviews in the ‘Achieving Quality and Effectiveness in Dementia Using Crisis Teams’ (AQUEDUCT) study.” The purpose of the part of the AQUEDUCT study is to evaluate an audit tool which measures best practice for Teams Managing Crisis in people with Dementia (TMCDs). The team were part of this evaluation process and received feedback from the research team; they have agreed to continue to support the next phase of research process which involves assessing the effectiveness of a specifically developed resource tool kit. The team are currently in the process of rolling out a research study in to the impact of digital technology in the lives of people with dementia. They are looking into purchasing a digital animal that would then be used within care homes for people with dementia; levels of well-being and behaviours that challenge would be assessed as part of this process. The team actively took part in the most recent CQC inspection process and the service was rated a good. The team have shared the feedback from the inspection in team meetings and discussed how they can improve on areas of practice for the future.
How will you ensure that your service continues to deliver good mental health care?
The service is continually reviewed and evaluated, as above. The RITT works closely with and has regular meetings with the local CCGs. We are currently working with commissioners specifically to look at the service provisions of people recently diagnosed with dementia; and how we support people best through from diagnosis to end of life care. We are engaging in ongoing negotiations with commissioners around continued funding for the Acute In- Reach role discussed earlier. We continually mentor and coach current staff to ensure their continued professional development so that they may meet the future needs of the service. They are nurtured and encouraged to consider how they may take steps forward in their individual careers and how this meets with the future needs of the service. This includes offering training and secondment opportunities where possible.
What aspects of your service would you share with people who want to learn from you?
The team have a number of different aspects of their role that they have and would want to share with others. These include the specific older adult crisis services, the In-reach services, the Care home clinics and the integrated neighbourhood team work. These have been outlined in detail earlier in the form. The main challenges are ensuring that people understand the need for change and are engaged in the process from the start; this is done by ensuring that they have their voices heard and feel part of the process. The Challenge is are moving away from traditional ways of working and shifting people from problem to solution focussed ways of working. We have held a number of team level meetings that have used a solution focused approach, to consider positive practice and planning the next stages in a concrete way.
How many people do you see?
Total Referrals in SPoA (Main access point) April 2018-March 2019: 1506 Total Referrals into RITT April 2018-March 2019: 728 Accepted Referrals into RITT April 2018-March 2019: 723
How do people access the service?
Monday-Friday 9-5pm- all referral go through Main Point of Access (MAP) Outside of these hours within our RITT working hours (8am-9am and 5pm-8pm Monday to Friday and 8-8pm Saturday and Sunday) referrals come through to main RITT. The team will accept referrals from: • GPs, and other Primary Care Health Professionals. • Multi Agency Safeguarding Hub (MASH). • Mindsmatters services for referrals requiring assessment outside the remit of Mindsmatters. • Community Restart Team. • Carer or patient’s relative, if appropriate for assessment team (out of normal working hours). • Self-referral, if appropriate for assessment team (out of normal working hours). Standard response times for referrals • immediate triage by call handler; • gatekeeping within 4 hours; • urgent same day face-to-face response (unless agreed with the referrer that same day not required) . Non- Urgent Referrals seen within 10 working days. Referrals are discussed every morning by the multi-disciplinary team- following triage and before assessments are arranged.
How long do people wait to start receiving care?
Non-urgent referrals are assessed within 10 working days. Urgent referrals made to the RITT- contact is made within 4 hours and then a decision is made whether face to face contact can wait until the next working day. We currently do not have a waiting list and so meet targets set within our Standard Operating Procedure.
How do you ensure you provide timely access?
Initial telephone triage by clinician. Daily MDT discussions around referrals. Daily allocation meetings with MDT.
What is your service doing to identify mental health inequalities that exist in your local area?
Liaising with Integrated Neighbourhood Teams to work holistically and address the mental health inequalities in people with long term conditions; as well as addressing the physical health inequalities for older people with mental health problems. Nominated equality and diversity champions.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
Access to physical health care for older people with mental health needs. Older people
What is your service doing to address and advance equality?
RITT follows trust policy in relation to advancing equality, which aims to follow relevant legislation. The team is working with the acute hospital trust and Integrated neighbourhood teams to ensure equity in access to services for people with co-morbid physical and mental health needs. Clinics within local care home to using a needs led model of care, encouraging and support care home staff to treat people within care with equity.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
We use measures standardised for an older adult population, following guidance from our outcome measures document. This document is developed from literature reviews and research around measure available for an older adult population. These include the Depression Anxiety and Stress Scale (DASS-21), The RAID (Rating of Anxiety in Dementia), The Cornell Depression Scale, The Abbey Pain Scale and the Challenging Behaviour Scale (CBS). The service also uses the comprehensive Health and social needs assessment and uses the STORM risk assessment documents to fully assess the risks of individuals we work with.
How do you meet the needs of people using the service and how could you improve on this?
For further information about how we meet the needs of people using the service is found in other areas of the form. We recognise that people are not always able to travel outside of their own home, so we work a flexible approach and try to facilitate visits within people’s own homes. When people are able to travel we will make use of local facilities across of the locality- using neighbourhood buildings. We support and encourage our staff members to access training to allow them to offer interventions to meet with NICE guidelines. We work closely with our acute trust and inpatient psychiatric services, as well as other community services (mental health and social care) utilising joint visits/working were possible to ensure people feel safe in their transition across services.
What support do you offer families and carers? (where family/carers are not the service users)
Carers assessments are undertaken routinely with consent from our patients. We also liaise and refer carers for additional carers assessments with social care. We are currently trialling a carer feedback group for partners who are carers for their spouse who has dementia. We aim to, with consent, to work collaboratively with carers, as much as possible. We ensure time is made within visits to listen to carers, which might include providing additional staff members to facilitate this. We respond to calls from carers, who are encouraged to keep contact with the services to share their concerns and difficulties about the service user or their caring role. We liaise with third sector services to ensure that carers are given the best support and ensure breaks and respite is offered before the breakdown in the carer role. Information about third sector services is given to carers in visits.
NCCMH mental health care pathways
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
If you have implemented any of the above, what were the benefits and challenges?
See early comments re: RITT in reach service.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): Blackburn with Darwen CCG and Pennine CCG
Provided by (e.g. name of NHS trust) or your organisation:
Lancashire Care NHS Foundation NHS Trust
Brief description of population:
Pennine Lancashire is a large geographical area, built up of 6 boroughs, with a resident population of 531,000; 17% of this population comes from a black or ethnic minority group. By 2035 people of the age of 65 and over will increase by 13-17%, with the number of residents over 85, currently at 11,000, being set to double. Pennine Lancashire has some of the poorest health in the country and people are likely to die earlier. It is estimated over 50% of the people have one or more long term conditions and mental health illnesses are more common than other areas of the country.
Size of population and localities covered:
Population Totals 65+: Blackburn with Darwen- 21, 291 Burnley- 16,170 Hyndburn- 14,669 Pendle- 16,773 Ribble Valley- 13,852 Rossendale- 12,807
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