This team is provided by Central and North West London NHS Foundation Trust. The service specialises in the care of older adults and frailty; however, the referral criteria is not based on age, but on needs. The team is integrated within the generic older adult community mental health team, which means that transitions are timely and seamless and duplication of work is almost eliminated.
This team is provided by Central and North West London NHS Foundation Trust. The service specialises in the care of older adults and frailty; however, the referral criteria is not based on age, but on needs. The team is integrated within the generic older adult community mental health team, which means that transitions are timely and seamless and duplication of work is almost eliminated.
The integrated team is multidisciplinary, including psychology, social care, psychiatry, occupational therapy, nursing and support work, as well as having regular input from arts psychotherapy and admiral nursing. The wider team provides medical, pharmacological, psychological and social interventions and works with other agencies such as care agencies, social services, primary care, third sector services, police, housing associations and environmental health. Visits from the HTT are one-to-one and usually more frequently than once a day. Consultant cover is provided by the same medical team, including daily input from the CMHT/HTT consultant.
The service has a target time from referral to treatment of 4 hours for emergency referrals, and 24 hours for urgent referrals. These targets are met 100% of the time for in-hours referrals. The HTT operates extended hours, 7 days per week. The person’s need for acute mental health care is assessed within 24 hours of acceptance and daily thereafter. Within the first 24 hours of the person being accepted to the service, mental and physical health needs and social needs are addressed. All staff are competent in assessing needs through a Care Act-compliant assessment. In addition, the HTT are now beginning to commission care packages in a case management model, reducing delays while waiting for allocation to a care coordinator in the community mental health team, and in some cases preventing the need for ongoing secondary care altogether.
The HTT operates a personalised and bespoke care planning model, which means that all new service users and carers receive personalised and recovery-focused care plans. The person’s care plan is developed with the person within 48 hours of acceptance for treatment, and families and supporters are kept updated with any changes to the care plan.
The HTT also provides weekly input to the inpatient unit, which allows proactive management of people requiring admission or those who need facilitated discharge. Because of this new integrated model, admission rates have significantly reduced, with the length of stay considerably lower than neighbouring older adult or general adult services.
The service actively seeks service user experience feedback through their bespoke, validated patient-reported outcome measure/PREM survey and through a monthly group meeting for active service users.
