The Rapid Intervention and Treatment Team (RITT) was established in order to provide a robust older adult mental health community service with a focus on keeping people at home and avoiding preventable hospital admission. The service covers people living in their own home and those in care homes as well as supporting people in hospital to receive safe and timely discharges. The service provides an urgent response to those in crisis and is able to provide a same day response with flexible visits up to four times per day. The service utilises pharmacological interventions where needed but is recovery focused promoting the use of non-pharmacological and psychoeducational techniques.
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 (RITT) was established in order to provide a robust older adult mental health community service with a focus on keeping people at home and avoiding preventable hospital admission. The service covers people living in their own home and those in care homes as well as supporting people in hospital to receive safe and timely discharges. The service provides an urgent response to those in crisis and is able to provide a same day response with flexible visits up to four times per day. The service utilises pharmacological interventions where needed but is recovery focused promoting the use of non-pharmacological and psychoeducational techniques. Prior to the establishment of the team there were no alternative options to admission for older people with mental health problems, including a lack of weekend and evening services. The service is unique in that it offers both scheduled and unscheduled care community interventions meaning it is able to flex in order to meet the needs of those in crisis regardless of if they are already known to the service or living at home or in a care home. This has greatly improved the continuity of care provided and reduced the number of handoffs within older adult mental health services. The teams have successfully supported patients to live in the community producing better health outcomes and enhancing the patient experience.
What makes your service stand out from others?
The service is flexible in its approach to patients and their carers. The service works in coproduction with patients and carers in order to design the most effective plan of care and recognising that the patient and carers are the experts in their own health. The team have a wide range of interventions that they are able to use and have close links with community resources to ensure patients are able to regain control and recover their live following the crisis. Below is a case example of a recent patient the team have worked with: Mr X was referred to services following the death of his brother, which he felt to blame for. He had withdrawn from all daily activities and was spending long periods of time ruminating over thoughts of his brother’s death. The self-blame had become so severe that he felt he no longer deserved to live and so attempted suicide. This was unsuccessful and Mr X was referred to RITT.
Mr X had a history of depression and anxiety and had historical hospital admissions. Mr X was assessed at home by RITT and was offered the choice of treatment. Mr X identified that he wished to remain at home with his wife. The team offered Mrs X a carer’s assessment as they identified the impact of recent events on Mrs X and her role in future risk management. It was agreed that RITT would visit daily to offer support to Mr X and his wife. Mr X had a timely medication review and a new treatment regime was implemented – the daily visits were used to assess for side effects and therapeutic benefits of the new regime. Mr X was offered the space to explore his thoughts and the time was used to help him understand and normalise some of his feelings. Advice and support was offered to Mrs X about how she might help her husband day to day. The early goal was identified of getting Mr X re-engaged with his activities and also helping him comes to terms with his brother’s death. The team offered OT support in terms of helping Mr X with management skills for his anxiety and identifying goals in terms of activity. The team limited the people involved to ensure consistency in approach and moving Mr X towards his goal. Ongoing risk assessment and management was discussed in each visit, with both Mr and Mrs X, because of her role in supervision and management of risk. Practical steps were taken and advice about future supervision discussed.
Mr X engaged well with the OT and daily visits and gradually support was reduced- he started to re-engage with some activities. Psychology was offered in order to assist Mr X with his feelings of guilt in relation to his brother’s death. Mr X was able to actively engage in thought challenging work and understand his role in his brother’s death. Again further information and normalisation of feelings in terms of bereavement process were given and understood by Mr X. Final assessment session – Mrs X was invited in with consent, to share the formulation and the work that had been undertaken. Mr X felt he had processed and made sense of his difficulties and how this linked with his risk. Mr X continued to have reduced support from the team and agreed a decreasing support plan for discharge. Mrs X was also included in this process to ensure her needs and concerns were addressed. Mr X safely discharged from the team after approximately 14 weeks. Key Points: – Patient choice in treatment – Least restrictive options explode and implemented – Carer’s assessment and support included in care plan – Consideration of patient goals and role of team from outset- and acknowledgement of changing goals throughout involvement – Team based approach, with timely and considered access to wider MDT- OT and psychology, as well as nursing and medication – Patient and carer involvement in discharge care planning
How do you ensure an effective, safe, compassionate and sustainable workforce?
When the RITT teams were first established this was a challenge for staff. Staff had moved from different teams and areas with different team cultures to work in these larger teams covering larger geographic areas. 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. Teams 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. The teams are also involved in a number of different fund raising events, for example one team is about to do a cross county walk in order to raise money for a mental health charity. 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. 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.
Who is in your team?
The team is made up of experts by experience, occupational therapists, nurses, medical staff, psychologists, mental health workers, support workers and administration staff. Each team is has a team manager and a deputy team managers who work alongside professional leads.
How do you work with the wider system?
The service requires all aspects of health and social care to work in partnership. The team work with the local authority in order to review placements in care homes and ensure that placements can be preserved where appropriate in order to reduce the need for placement moves. The local authority also work with the team to implement packages of care at home. The team also work with primary care services and have robust links with the mental health practitioners within those teams ensuring that physical health and mental health needs are paramount. The team link with the hospital liaison services in the acute trusts to ensure continuity of care for patients who are admitted to hospital or attend A&E. The team have also developed effective working relationships with a large number of private care home providers in the locality. The team work closely with community and third sector organisations to ensure patients can continue to live a full and happy life in their local community both whilst the team are involved and beyond.
Do you use co-production approaches?
Coproduction for this service is paramount. The team maintain that the patient and carer are the experts in their life and we are a guest helping to facilitate their recovery with them. The team listen to feedback about the service and worked with experts by experience in order to produce well communicated service improvements.
Do you share your work with others?
The team have recently been visited by a neighbouring mental health trust who were extremely interested in RITT as they have no crisis offer for older adult service users. The team engage in best practice groups in order to share new developments and quality improvements that are taking place. In June 2018 we have been asked to present the model of RITT to the Yorkshire and Humber Older Peoples Clinical Mental Health Network meeting as they are keen to hear how crisis services can work for older people. The team are also presenting at a Quality Improvement Conference in May 2018 about the work they have done with care homes to support patients.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
The evaluation of input into care homes was mainly via feedback from the care homes. We found that 100% of care homes involved reported that RITT helped them to understand the patients better. 74% reported that RITT had benefitted all of the residents within the home due to staffs increased knowledge and confidence. The services uses a variety of formal outcome measures but they are most proud of the narrative feedback gained based on the patient experience. I will provide two examples below: “Thank you for 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 did care. I cannot thank you enough” “I was in a deep pit with suicidal thoughts and I didn’t want to live. The RITT team 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 the 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 service was visited by a neighbouring mental health trust who are looking to replicated the model of RITT within their older peoples mental health service. The most recent CQC visit to RITT rated it as good in every domain.
How will you ensure that your service continues to deliver good mental health care?
The service is well established and have continued to function, despite significant demand and during times of management changes. During a recent conversation with a lead commissioner they highlighted that they didn’t feel we shouted enough about the excellent work that goes on within RITT which lead to this nomination. Commissioners have asked Adult crisis teams to review the RITT model and learn from the processes and culture that have been developed.
What aspects of your service would you share with people who want to learn from you?
RITT started as a big bag approach. If I were to do this again I would have a much more detailed plan of how to tackle issues of different team cultures coming together. After the start of RITT commissioners stopped some non-recurrent funds which impacted on out ability to run the full model to start with. This was resolved with commissioners after a service evaluation and funding was actually increased.
How long do people wait to start receiving care?
Urgent referrals are seen same day. Routine are screened within a week and seen within two weeks.
How do you ensure you provide timely access?
All referrals into Older Adult services are screened by RITT to ensure anyone in crisis can be seen without delay.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
All patients are under CPA. Professional assessment tools are used throughout.
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?
Lack of funding for older adult liaison specifically. Lack of funding to meet core 24.
Brief description of population (e.g. urban, age, socioeconomic status):
Lancashire has a population of approximately 1.5 Million and has areas of serve deprivation and poor health outcomes. Lancashire is a large county covering 1200 square miles
Size of population and localities covered:
1.5 Million. The service covers the whole county made up of 8 CCGs, 3 local authorities and 4 acute Trusts.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
Blackburn with Darwen (Lead MH commissioner)
Provided by (e.g. name of NHS trust) or your organisation: *
Lancashire Care NHS Foundation Trust