The SW HTT has developed a number of systems to improve it delivery of care, focusing on a holistic and inclusive approach to service users and their carers. It has devised clear pathways for all service users and their carers who are in crisis/relapsing in their mental health. Key changes have been made recently with regard to the way the team liaises with the in-patient services, developing an assessment tool for Support Time Recovery workers (STRs), a checklist for carers and developing a programme of audit/feedback for service users and carers.
Co-Production
From start: No
During process: Yes
In evaluation: No
Evaluation
Peer: Yes
Academic: No
PP Collaborative: Yes
Find out more
Jane Harris - Communications Manager, Sheffield Health & Social Care NHS Foundation Trust
The SW HTT has developed a number of systems to improve it delivery of care, focusing on a holistic and inclusive approach to service users and their carers. It has devised clear pathways for all service users and their carers who are in crisis/relapsing in their mental health. Key changes have been made recently with regard to the way the team liaises with the in-patient services, developing an assessment tool for Support Time Recovery workers (STRs), a checklist for carers and developing a programme of audit/feedback for service users and carers.
The role of interfacing with the in-patient service was developed with the attached located in-patient team in the South West of Sheffield. A six-month pilot was took place which involved the band 6 nurses and the Senior Practitioner in the HTT working into the in-patient team. During the working day a nurse would visit the ward and identify all in-patients who lived in the SW area. A computer programme was devised and used to capture the service users alongside a plan of action for the HTT. Over the 6-month period the HTT staff worked closely with the in-patient staff in planning care and discharge packages with an emphasis on early discharge into the HTT. This included service users being assessed by the HTT while on the ward so that the assessment could help inform the whole care team with regard to the care plan and treatment. Where someone was identified as ready to go on home leave the HTT would arrange this in order to ensure that during the home leave, they were visited at home by the HTT for assessment purposes. This helped to focus the service user’s ability to cope at home, any social care needs that may need addressing that may not be so easily picked up on by the ward staff, compliance with medication and any concerns that the service user or carer (if involved) may have around discharge from the ward and support in the community. The HTT also ketp in contact with the carers to talk to them about any concerns they had regarding discharge planning. The pilot was audited by giving feedback forms to the service users and carers. The general feedback from service users and carers was positive as was the feedback from the in-patient staff. The positive result of the pilot was that this approach was then embedded into everyday practice.
Wider Support
As part of the interface with the in-patient services the team worked closely with the in-patient team and also the local Crisis House which offers further support for service users under the care of the HTT. As the interface with the in-patient team was so effective the team now have developed links with all the three in-patient teams so all service users who are admitted to hospital received this enhanced level of care. In terms of carer support the team identified a carer lead in the team who linked in with the carer services including Rethink Carers Service and the Sheffield Young Carers Service. The work that the STRs undertook involved working closely with the other Community Mental Health Teams (CMHTs) in Sheffield in order to ensure that work that had already been started was not derailed and also that it was carried forward by the STRs in the HTT. In addition the STRs have worked closely with multi agency organisations, building up relationships with the benefit services, housing, voluntary organisations and more recently with the GP Community Support Service.
Co-Production
As part of the changes within the HTT we wanted to ensure that the views and opinions of both SU and carer were considered. In order to do this we conducted two pieces of audit based on SU and carer feedback. The team worked with the SU and carers by informing them of the planned changes that the HT were going through to improve care deliver and asked for experiences and suggestions in relation to how the team could be improved. From the feedback we set up a forum for both Su and carer to enable a more structured approach in working alongside each other to improve services.
For the interface work we used a feedback form in order to establish if the work we were doing was making a difference to the service users’ and carers’ experience of in-patient care, discharge planning and transition in to the HTT. The audit is in the Outcomes section. As part of the development for addressing the needs of carers and supporting them during the cared for persons admission into the HTT a feedback form was given to the carers once the service user was discharged from the team. The audit is in the Outcomes section.
As part of ongoing care improvement the HTT has committed to having an on-going programme of audit that focuses on the views and opinions of service users and carers. The HTT are currently developing a way of gaining feedback from service users in relation to their discharge experience. This was decided on based on the feedback from carers regarding the level of care provided once discharge from the HTT back into the CMHT. Although the HTT are not responsible for the delivery of care by the other CMHTs the whole discharge experience is important for the service users and carers and we would like to ensure that the whole experience from the HTT is right and where there are changes needed in CMHTs the HTT may be in a position to influence how things work from HTT to CMHT.
Looking Back/Challenges Overcome
The main challenges to this process, was the amount of time and work it took as a team to make so many changes. The team did have set time scales as well as allowing itself time to reflect on progress made and also re visit time scales and plans. One of the main areas of achieving change was having a whole team away day to do specific focused group work on a variety aspects of care.
Sustainability
Due to the nature of the work we do, we have adopted a good team approach to aspects of care. We included the administrator for the team throughout the whole process and they have got their own specific schedule for monitoring aspects of care alongside governance of trust wide expectations and CQUINNS. The administrator has developed a handbook for administrative staff so if for whatever reason they are not at work another worker can come in and cover the work they were doing. There is a clinical operational policy specific for the SW HTT that has been devised in order for new staff who start in the team to follow. The band 6 nurses keep a log of some of the aspects of care and during their daily coordination role are able to use the documents that have been developed, for example the MDT template (see appendix) to easily check how standards are being met.
Evaluation (Peer or Academic)
Once the changes had been made by the team, a decision was made to apply for Accreditation with the Royal College of Psychiatrist. This was achieved and granted in December of 2016. The review team were particularly impressed with the work we had done with the STR and Carer checklists and we were asked to present at their forum . They have since invited us back to present at one of their training events in June on power relationships including the ones within teams based on them finding a “flat hierarchy” within the team that they picked up on during the review. This was also picked up on during the presentation we gave at the forum as we the STRs did most of the presentation.
Outcomes
AUDIT OF PILOT OF INTERFACE FROM SW HTT TO BURBAGE WARD
During the six month pilot a total of 42 patients were admitted to the ward. Of these patients 23 were identified as needing HT and came onto HT at point of discharge from the ward.
For those patients who were not taken on reasons included;-
Patients who had moved out of the area covered by the HTT.
Patients rehoused in 24 hour supported living accommodation and care needs did not require additional HT support.
Patients admitted to a general hospital ward.
Patients judged to be more suitable for other services or own community mental health team.
Patients who expressed an unwillingness to engage with the HTT.
Patients who had previously been managed by the HTT where the outcomes were poor.
20 patients who were admitted to the HTT were given a satisfaction questionnaire at the point of discharge from the HTT. Where there was a carer involved, a carer questionnaire was also sent out.
Of all those 20 patients 14 had an identified carer and forms were sent to them all. A total of 9 (47.5%) patient satisfaction forms were returned and a total of 10 (71%) carer forms were returned. This is a good response for postal questionnaires.
Free text responses included: “As a family we have been absolutely supported in a timely way. The HTT have asked the right questions and actively listened to us. The negotiation process that was carried out by the hospital staff, the service user, ourselves and the HTT was well communicated. We are not sure how the HTT can be improved because the focus of the contact was for the service user”
“Overall we felt the service was very good”
“I think it is needed as a bridge to get people back home and back in the community. I also think the HTT helped by giving the hospital their input of how they thought our daughter was doing and what may help her to move forward”
FINDINGS
The results of this pilot showed that the majority of service users and carers found the contact with the HTT during transition from inpatient to HTT helpful. Of the overall 35 scores for the service user questionnaires, 32 were rated as either very helpful/unhelpful., with only 1 score being slightly helpful and 2 being unhelpful. Of the 25 carer’s scores, 23 scores for contact rated it as helpful/very helpful with 2 scores of slightly helpful. 2 carers who did not have contact on some aspects of the process said they would have found it helpful.
A number of free text comments were made. One carer had expressed concern about the way her son had been discharged from the ward and this was a patient who did not have any contact with the HTT prior to discharge. We could surmise that if contact had been made whilst on the ward that the carer’s experience might have been more positive.
It would appear that the overall feeling from patients and carers is that the HTT interfacing with the ward and having involvement with them whilst they were in hospital, during periods of leave and being under HTT post discharge was very positive and valued. The level of responses from the questionnaires was high especially from carers. This may indicate the importance of giving feedback to care teams by service users and carers.
CONCLUSION
Admissions to acute psychiatric hospitals can be a particularly stressful time for both service user and carer. Lack of information and uncertainty regarding discharge can add to this stress. Any interventions that help service users plan their recovery and ongoing care from the ward back to the community can only be positive. If carers have a point of contact between hospital and community then this is likely to help with communication and knowledge of how their relative’s care is progressing.
With such a positive feedback it would be sensible for the HTT to look at how they roll this pilot out to other inpatient wards where patients are admitted.
The HTT nurses feedback from their experience of visiting the ward was also positive. It was felt that this had been a useful way of working and that it needed to be rolled out to other wards.
There were no areas of practice that were reported as not being needed and feedback over all areas of interaction during admission, leave and HTT were generally deemed as positive. It is therefore important that practice that appears to improve service user and carer experience continue.
Sharing
Within Sheffield there are three other HTTs. We have throughout the process of change worked with the other teams in order to pass on good practice. In order to ensure that the teams are able and supported to work in the same way as our team, we have been supported to work with one team at a time in order to make the bigger changes. We have an away day booked next month and the teams have agreed for our staff to visit their team in order to guide them through processes. As mentioned above we have shared our work with the HTAS and we have also presented at the Trust’s in-patient and CMHT development group. The work we did with the STRs and around carer support has also now been picked up by the Sheffield city wide Early Intervention Service. We have also been asked by other Home Treatment Teams around the country to facilitate a visit to the team to see how we work.
Is there any more information you would like to add?
The SW HTT will continue to interface with Burbage ward as this is where the majority of their patients are admitted. It was agreed by the Trust to fund the band 6 post on a permanent basis to allow this role to continue with the plan to expand to all the other inpatient areas. All the Four HTTs will appoint a band 6 nurse so that this work will develop across all teams providing continuity of care across the whole city. There are now only three inpatient wards since the end of March 2016, so there is no designated ward for each CMHT. There is however an agreement for service users in the south of the city to be admitted to Netheredge Hospital. The SW will start to interface with Stanage ward and replicate the work that is being done on Burbage Ward. The interface nurse will forge links with Maple ward in the north of the city in order to develop a good relationship with the ward and help them determine patients who may benefit from HTT, if they do get any of the SW service users admitted, which are usually very few and far between.
We want to maintain the standard of care that was commented on by one of the carers during this pilot
“As a family we have been absolutely supported in a timely way. The HTT have asked the right questions and actively listened to us. The negotiation process that was carried out by the hospital staff, the service user, ourselves and the HTT was well communicated.”
“I think it is needed as a bridge to get people back home and back in the community”
The STR checklist was developed by the wholeteam but the project leads were the STRs themselves in the team. In order to ensure a good standard of assessment and care around areas of physical health, social care and carers, the checklist was developed as part of the HTT care pathway. Once a service user comes into the HTT and has been seen by a qualified nurse, an appointment with a STR is made. This is planned early on in care unless there is a clinical reason for it not to be. The STR then goes through the checklist and once completed will identify action plans in co-production with the service user. Once agreed these are added to the Collaborative Care Plan. The STRs will engage with any of the identified goals and will plan interventions alongside the rest of the HTT care plan.
The STR checklist identifies if there is a carer present, once this has been established then the STR will book in for either an STR or qualified nurse to make contact with the carer to arrange the carer checklist. The carer guides the staff in terms of if they want to do this at home or over the phone. As well as asking if the carer wishes to have a carer assessment in their own right, it also asks about current support they have, arranges referrals to the carers centre, furnishes the carer with contact details and information about the HTT and offers an opportunity to meet a qualified nurse in order to discuss issues around diagnosis, care and treatment. Any actions identified from the carer checklist are then put in place. The carer is asked if they would like the HTT to make contact with them again while the loved one or relative they care for remains under the HTT.
This work was audited by sending out carer feedback forms over a period of six months.
