Integration between Physical and MH Intensive Home Support Team – Lancashire Care NHS Foundation Trust. (ARCHIVED)

The Intensive Home Support Service is an existing services which (IHSS) closely monitors patients within their own homes to prevent inappropriate admissions to acute hospital. They will also step patients up to hospital should they require it and make appropriate referrals where necessary. The IHSS provide Nursing and Therapy assessments and we have worked with commissioners to ensure that teams now have a Mental Health Nurse in post to promote their patients wellbeing whilst they are under the IHSS. This provides a holistic approach to patient care. The IHSS had developed an understanding that patients with long term conditions or life limiting illnesses often needed support regarding their mental wellbeing, but previously had few ‘real time’ services/professionals to help with this.


  • From start: Yes
  • During process: Yes
  • In evaluation: No


  • Peer: No
  • Academic: No
  • PP Collaborative: Yes

Find out more



What We Did

The Intensive Home Support Service is an existing services which (IHSS) closely monitors patients within their own homes to prevent inappropriate admissions to acute hospital. They will also step patients up to hospital should they require it and make appropriate referrals where necessary. The IHSS provide Nursing and Therapy assessments and we have worked with commissioners to ensure that teams now have a Mental Health Nurse in post to promote their patients wellbeing whilst they are under the IHSS. This provides a holistic approach to patient care. The IHSS had developed an understanding that patients with long term conditions or life limiting illnesses often needed support regarding their mental wellbeing, but previously had few ‘real time’ services/professionals to help with this.
In October 2016 a Mental Health Nurse began working within the IHSS. The Nurse is embedded within the service and offers Mental Health Assessments when staff within the team have concerns about a particular patient. There are no set criteria for assessment other than a concern raised by staff or a patient requesting assessment. This has meant fewer barriers to accessing Mental Health involvement, mental health assessment being seen as natural, with many patients having the opportunity to be assessed by the Mental Health Nurse, advice given and signposted to the more appropriate services where relevant. Due to physical frailty and being housebound, patients within the IHSS have benefitted from more flexible Mental Health involvement as a lot of the patients referred to the Mental Health Nurse would be unable to access services often normally provided in clinic based services. This new service has ensured equality of access to mental health services all too often denied those who are older and frail because the existent services do not offer home based assessments. Having Mental Health input within the team has provided a quick response to patients by a Mental Health Professional, plans implemented from the assessment, appropriate information shared within the team and patients signposted or referred on to various services when required.

Wider Active Support

Within the IHSS the Mental Health Nurse works with fellow professionals within the team, such as Nurses, Occupational Therapists, Physiotherapists and Social Workers who all seek assessments for their patients should they have concerns about a patient’s wellbeing. This also works the other way where the Mental Health Nurse will refer patients where concerns are raised regarding their physical health, working as an MDT to provide a holistic and individualised approach for the patient. Cross over between health organisations has also occurred where the Mental Health Nurse has highlighted patients already open to Secondary Mental Health Teams or has referred appropriate patients to them when required. The IHSS Nurse has worked closely with Mental Health Services to support both the patients physical, social and mental health needs in order to achieve the best possible outcomes. Accessing services that would not normally be easily available to patients solely under Secondary Mental Health Services, such as emergency respite care, care packages and medication management services. It has also meant that the patient’s physical health needs and mental health needs can be addressed simultaneously and closely monitored.
Following assessments patients have been signposted to a variety of partner organisations in order to have their needs addressed. These have included, referrals to Secondary Mental Health Services, Memory Assessment Services, their GP, Minds Matter (IAPT), OT (Integrated Therapy Services), Wellbeing Services/advocacy, Food bank, Hospice, Bereavement Counselling, Drug/alcohol services, Smoking cessation, Pulmonary rehab, Age UK, Home library services, Social Services, Police, Carers link. Joint work has also been completed with the Integrated Neighbourhood Teams when patients have been under both services. From the assessments completed the needs of patients have varied in complexity, thus requiring involvement from a wide range of partner agencies.


Staff Feedback
“Having the mental health aspect of IHSS is essential to our everyday provision. It allows IHSS to provide a true multidisciplinary holistic approach. Having a mental health resource available to patients enhances our ability to prevent current and future admissions. It has enabled quicker more appropriate access to services to support staff and patients in care planning. Having the availability to discuss those complex cases and situations in a timely manner facilitates an excellent responsive preventative proactive service.” Amanda Whitley IHSS Locality Lead. “I have seen Jane develop her role in IHSS very successfully and have witnessed many significant benefits of having her skill base with in the IHSS service. Patients have received seamless care with no barriers in waiting for appropriate support. Jane’s role has narrowed the gap between physical and mental health care provision. I hope with the combined support of different health professionals such as Jane and mental health nurses, further options can be offered to patients in the future. Jane has also used her knowledge to further the knowledge of others in the service and has been dynamic in ‘fitting’ in with the service objectives. Thank you Jane!” James Earle IHSS Locality Lead.
“I found it useful to have access to an RMN assessment during my review of the patient.” Lisa Towers, Community Matron, IHSS.
“I have found your input valuable as have the patients. I have listed a few below:
1 Advice and information for clinicians
2 Quick response time from referral to assessment
3 MH diagnosis, sign posting patients and referral onward for long term MH support
4 Input on capacity assessment
5 Jane is a valued member of the team.” Margaret Bennett, Community Sister, IHSS.
“I have found your input invaluable as it adds another dimension to our assessments. We are able to offer a more holistic approach and the realisation that mental health also affects physical health has been made even more obvious. We have had some complex patients recently and would have had to refer them to outside mental health services which inevitably would take a lot longer. Having a mental health nurse here, to be able to discuss patients at length is great.” Debbie Jennings, Community Matron IHSS.
“Excellent service and much needed.” Alison Roberts, Community Sister IHSS.
Patient Feedback
“It was good to be able to talk about my concerns with someone outside of the family as I often feel they get fed up with hearing about my problems.” Patient 1
“I felt listened to and my concerns were acknowledged and acted upon.” Patient 2
“There has only been good points to having you involved.” Patient 3
“I felt like you understood what was happening to me and you listened.” Patient 4

Looking Back/Challenges Faced

When the project was first considered it was thought that 2 Mental Health Nurses would be required due to the size of the geographical patch and the number of referrals received by the team. This was then considered and a plan put in place to initially put 1 Mental Health Nurse in post to pilot what the need was within the service.
Following having one Mental Health Nurse in post for just over 3 months and receiving over 100 referrals during this time it is felt that the service would benefit from an additional Mental Health Nurse. This would also mean that the service could develop and expand to provide further input with patients referred for Mental Health assessments and work into the Integrated Neighbourhood Teams.
The pilot has highlighted a gap in service provision for people who experience long term conditions or life limiting illnesses that are not appropriate for Secondary Mental Health involvement and cannot access clinic based mental health services. The service is different to IAPT in that a patient is assessed by a Mental Health Nurse within their home environment, provided with short term input until appropriate care or treatment is established and if required signposted to the most appropriate service to meet their needs and maintain or enhance their wellbeing. IAPT are currently piloting a service for individuals with long term conditions, however this service remains clinic based and this prevents certain groups of patients from being able to access the service. IAPT do provide telephone appointments and this is something which can be offered to patients who are housebound or unable to access clinics. Some patients are accepting of this telephone service whereas others prefer a face to face appointment.


The challenge for the future is commissioning this service to ensure the gap is filled and patients have access to Mental Health Care if they cannot access the IAPT service. The other challenge faced is finding experienced staff who are able to carry out the role as it requires experienced, motivated and enthusiastic staff who are capable of driving the service forward and have the ability to work independently and provide the best possible service for their patients


Evaluation (Peer or Academic)

The Mental Health Nurse within the IHSS has collated data as part of the pilot. From October 2016 until February 2017 the Mental Health Nurse had received 136 referrals.
As the role has developed the Mental Health Nurse has signposted patients to a variety of services and partner agencies to seek support for their mental wellbeing.  Attached is data from the pilot which highlights how many patients have been seen within the month and where patients have been signposted to. 2 case studies have also been included to highlight the work undertaken with patients in order to achieve positive outcomes.

Case study 1
• 53 year old gentleman suffering from depression and pain management issues following a spinal injury. Difficulties with mobility and pain management.
• Prescribed Mirtazapine and Diazepam.
• Experiencing suicidal thoughts, he was frightened and upset, previous suicide attempts, history of abusing alcohol, now stopped drinking. He was tearful, low in mood and lacking motivation. Appeared unkempt.
• Previous involvement from Mental Health Services.
• Environmental / Housing issues as patient struggling to leave his flat due to struggling to walk up the steps outside to get to his car. Feeling restricted.
• Finding it difficult to manage tasks such as sorting out bills and was struggling financially. He had very little food in the property.
• In debt and struggling financially.
• Son lives with him – concerns re lack of support, difficult relationship.
• Protective factors were his family and his parrot.
• Services involved: IHSS, INT, Wellbeing Service and Social Services to address issues with finances, housing, pain management, OT assessments for equipment.
Outcome • Referred to food bank for food to be delivered.
• Referred to Mental Health for Urgent Mental Health Assessment due to suicidal thoughts.
• Referred to pain clinic via Clinical Lead.
• Wellbeing Service assisting with housing and finances – referred to Citizens Advice Bureaux.
• OT assessment and equipment provided.
• Physio assessment completed.
• Weekly review, support and monitoring from Mental Health Nurse.
• Supported patient through meeting with Social Services as was causing him distress.
• Improvement in mood.
• Improvement in appearance.
• Increased motivation to resolve his issues and seek help.
• Reduction in suicidal thoughts.
• Referred through to Community Restart to assist in engaging back in the community.
• Becoming involved in helping others and providing support.
• Discussing his future needs regarding his care, finances and housing options.
• Reduction in reviews from Mental Health Nurse.
• Joint review to be completed with Wellbeing Services to discuss needs and future support.
• Awaiting Mental Health Assessment.
• Assisted by Community Restart to find appropriate accommodation
Feedback by James Earle IHSS Locality Lead regarding Case study 1
Jane’s involvement with IHSS significantly improved this gentleman’s life. When I originally referred him to Jane, Mr S was a very depressed man, with significant suicidal ideation and a feeling of complete hopelessness.
Through Jane’s continued involvement and perseverance, Mr S began to engage better with different services and has now been rehoused due to her support. He now talks more positively and because she considered all of his holistic needs, he is far less isolated. From a different perspective, his impact on acute services should be much less in the future.
Jane made the biggest difference to this gentleman’s life that witnessed as a health professional. Due to her support he has now gone from a depressed man with a feeling of hopelessness to a man who engages and looks to a future with more promise. Jane never gave up on Mr S and as a result he built up a level of trust in her which was key to his improvements. As much as Jane’s personal touch was a big factor in achieving this, her mental health skills and knowledge were essential in addressing Mr S’s needs appropriately.
Case Study 2
Initial assessment
• 70 year old lady referred for Mental Health review by nursing staff concerned due to anxiety and low mood. Her physical health had been assessed as stable by the Nursing staff within IHSS.
• Patient had a diagnosis of Lupus, Reynaud’s disease and was referred through to IHSS with respiratory condition, Heart Attack in May 2016.
• On initial assessment patient was tearful, anxious about her physical health and was low in mood. Her sleep pattern was poor as was her diet and appetite.
• Patient had dropped many activities and did not like going out, her husband was completing a lot of the household tasks. She used to enjoy shopping and gardening.
• The patient had planned a holiday to Australia to see her children; however she had since cancelled the trip due to her poor health and anxieties. She told me she couldn’t face the journey.
• She was frequently using the internet to look up perceived symptoms of her condition and then worrying about them, linking them to her health complaints and increasing her anxiety.
• During the assessment I identified that the patient was prescribed mirtazapine 15mg, however she had not been taking the medication. I provided information and advice about the medication. I encouraged her to take them and planned to review her the following week. During the initial assessment advice and support was provided.
Follow up visit 7 days later
• I attended a week later to review the patient. She had commenced the medication. Her sleep pattern had improved, as had her appetite and she was going out daily with her husband. She was less anxious and reported that she had been less tearful.
• She was looking at her symptoms less online as she had acknowledged that this was impacting on her mental wellbeing. We discussed other coping strategies such as writing down her symptoms and then discussing them with her consultant at her next review.
• The patient was also considering rebooking her trip to Australia to see her family.


Follow up Telephone call 3 weeks later
• I contacted patient on the telephone 3 weeks after the follow up review. Patient reported she had a good Christmas and New Year. She informed me that she felt well and that her mood had improved as had her sleep pattern and appetite. She did not feel she required any further involvement at this time. She was planning on rebooking her trip to Australia.


This work stream is shared wider across Older Adult Mental Health Governance Meetings, Joint Forums with East Lancs Hospital Trust.

Additionally, this success and working practice is shared on a monthly basis through ‘Best Practice Groups’ within OA LCFT.






Share this page: