Manchester Assertive Outreach

What Does The Service Look Like?

The assertive outreach service consists of the following staff, organized into three teams, one for each locality.

POST	NORTH	CENTRAL	SOUTH
Team Manager	1	1	1
Community Mental Health Nurse	4	4	3
Support Worker	1	1	1
Social Inclusion Worker	1	1	1
Occupational Therapist	1	1.5	1
Social Worker	3	3	2
Clinical Psychologist	1	1	1
Consultant Psychiatrist	0.5	0.5	0.5
Staff Grade Doctor	0.5	0.5	05
Housing & Welfare Rights Worker	0.5	1	0.5
Administrative Support	1	1	1

The team structure is closely modelled on the staffing structure recommended in the assertive outreach section of the Mental Health Policy Implementation Guidance (Department of Health 2001). The key departure from PIG recommendations is the incorporation of Housing and Welfare Rights workers into the teams, reflecting a particular need of assertive outreach service users in Manchester.

The team managers are accountable to the Assertive Outreach Partnership Board, and via this board to the two organisations. The board is made up of representatives from each organisation, alongside a representative from the Joint Commissioning Team, who fund the service. The board is responsible for governance, service development and delivery, contract monitoring and performance management issues.

Who Do We Work With?

We provide care and support to people with severe and enduring mental health needs who have previously experienced difficulties engaging with mainstream mental health services. We aim to reach people who are not meaningfully engaged with services or who have been lost to services. Many of our service users have been caught up in a pattern of frequent psychiatric admissions to hospital and disengagement from community mental health services on discharge, followed by further admissions. The assertive outreach service works intensively with service users to assist them in breaking out of this cycle. Our aim is to help service users achieve greater mental and social stability in order for them to stay out of hospital and enjoy an improved quality of life.

We do not close cases when people find it hard to work with the service: rather we are quietly and assertively persistent, continuing to offer support to our service users until they no longer require our service. We aim to reach people of different cultures, including people from the African Caribbean and Asian communities. 32% of assertive outreach service users in Manchester in November 2006 were from BME groups.

Many of the people we work with have complex needs, including problematic drug use and periods of homelessness. This does not exclude them from the service: we work with them to providing a collaborative and holistic service that considers social needs as well as mental health needs. As a service, we insist that one cannot talk about good mental health unless one also talks about decent accommodation, adequate income and meaningful pursuits and activities. That is one of the reasons why, as well as having a psychiatrist, nurses and social workers on the team, we also have support workers, social inclusion workers and specialist housing and welfare rights workers.

Referrals

We take referrals from any source, including self-referrals, to ensure that no members of hard-to-reach groups, such as entrenched rough sleepers with severe mental health needs, who may be almost completely hidden from mainstream mental health services, are excluded from receiving a service. However, we operate to very strict referral criteria to ensure the service works only with those who would potentially benefit from it most.

Referral Criteria

1. The person lives within the City of Manchester.

2. The person is aged between 15 – 64 years.

3. The person has severe and enduring mental health needs (e.g. schizophrenia, major affective disorders) associated with a high level of disability.

4. The person has a history of high use of in-patient or intensive home-based care (e.g. more than two admissions or more than six months inpatient care in the past two years).

5. The person has difficulty in maintaining lasting and consenting contact with services.

6. The person has multiple and complex needs including a number of the following:

a) History of violence or persistent offending;

b) Significant risk of persistent self harm or neglect;

c) Poor response to previous treatment;

d) Dual diagnosis of substance misuse and serious mental illness;

e) Detention under the Mental Health Act on at least one occasion in the past two years;

f) Unstable accommodation or homelessness.

Interventions

The sorts of interventions we offer include but are not restricted to the following:

o  Assertive engagement;

o  Frequent contact;

o  Basics of daily living;

o  Support for families and carers;

o  Prescribing, administering and management of medication including management of side effects;

o  Psychosocial interventions including cognitive behavioural therapy and family intervention therapy ( Click on the link below for further information );

MAO_PSI_Leaflet.pdf

o  Interventions around substance use, including detection, assessment, harm reduction and motivational interviewing;

o  Interventions around co-existing common mental health needs (depression and anxiety);

o  Assessments and support around training, education, volunteering, leisure activities and social activities;

o  Regular assessment of core physical health needs and support in accessing physical health treatment;

o  Support around housing, homelessness and welfare rights;

o  Relapse prevention planning;

o  Crisis resolution and crisis intervention work;

o  Hospital in-reach;

o  Practical help and support around, for example, moving into and maintaining accommodation.

The Team Approach

We operate the whole team approach. Whilst all service users have a named care co-ordinator responsible for overseeing care and ensuring the care plan is regularly reviewed, the actual delivery of care is done by the multi-disciplinary team as a whole. This means that continuity of care remains, even if individual team members move on. All team members know and work with all service users, to ensure continuity of care and equitable access to all skills, knowledge, resources and experience held within the team.

In the assertive outreach whole team approach, team members view their specialisms as a resource for service users and for the rest of the team. And whilst we support and positively encourage lifelong learning and continuing professional development, no-one in the team can afford to be too precious about their own professional role: when working with hard-to-engage service users the Marigold approach - getting stuck in to get the job done – has to be adopted.

The application of the team approach this service uses has been developed over six years and results from testing out the suitability of a number of different versions and from discussions with other assertive outreach teams via the National Assertive Outreach Forum. CPA care co-ordinators are responsible for ensuring that the MANCAS needs assessment is completed at least annually and that the CPA care plan and the risk assessment are reviewed six-monthly. The care co-ordinator also acts as first point of contact for service users and carers. Each service user also has a back-up care co-ordinator who deputises as required.

Where possible, care co-ordinators are allocated on the basis of service user preference, geographical location, matching team members' skills to service users' needs and the strength of the relationship between the service user and the team member. However, systematic application of the team approach means that these factors are less important than they would be in a team that emphasised a key working approach.

The team approach is planned via the weekly planning meeting and the daily handover. Allocation of team members for visits is done with reference to the service user's care plan, any crises or current difficulties and the team member's skills, availability and relationship with the service user. Team members are also allocated to attend ward rounds, CPA reviews, appointments with other agencies, etc.

The information is recorded weekly onto an interactive Smart Board, which acts as the team diary and is updated at daily handover. At handover, crises and emergencies are discussed and team members allocated to cover them; any information relating to contact with service users or carers in the previous 24 hours is handed over; any tasks arising from this are allocated and any information required for visits occurring during the next 24 hours is handed over.

Assertive Engagement

Newly referred assertive outreach service users tend to have complex needs and engagement issues characterised by hostility to or suspicion of mental health services. 70% of service users had a dual diagnosis of severe mental illness and problematic substance use in the 12 months to November 2006 and 44% had contact with the criminal justice system in the same period.

We employ the following strategies for assertive engagement :

o       Frequent attempts to visit at different times of the day and week including weekends, early mornings and evenings to ascertain when successful engagement is most likely;

o       The 'in vivo' approach, where attempts at engagement are made in the service user's own home or locality, with flexibility where the service user indicates this is not desirable;

o       The use of advice, advocacy and support around housing, welfare rights or debt as an engagement tool – our experience suggests this is often the best engagement tool with disengaged service users;

o       Early contact with carers and other family members, who often have many years experience and knowledge around what engagement strategies will work and who can often provide crucial guidance and information;

o       The 'no close' approach, where repeated refusal to engage, or in some cases, to even open the door, does not result in the case being closed;

o       HARP's track record: many service users who have disengaged from mainstream psychiatric services have continued to use HARP services. The relationship of assertive outreach with other HARP services has allowed for improved engagement;

o       The association of the service with the voluntary sector service has allowed a perception of distance from mainstream psychiatric services that has helped overcoming suspicion and hostility, to enable other aspects of the service to be gradually introduced;

o       The willingness of team members to have 'a brew and a chat' with a service user – a very low-key intervention to start the process of building a relationship;

o       The clinical skills the Trust brings to the partnership, which gives engagement the goal of increasing stability and concordance and promoting recovery.  The service has to offer lower key, practical interventions to gain trust and build relationships before it can offer more clinical or psychosocial interventions. CBT practitioners within the team can them offer such interventions when it becomes possible;

o       The relevance of the service to service users' own identified needs, delivered in a culture where actively listening to what service users want is central to the care planning process;

o       The emphasis from the outset on partnership, collaboration and the service user as the expert on his or her own experience.

Hours Of Operation

The service operates for 365 days a year. The service is open from 8.00 am to 8.00 pm including weekends and bank holidays, with core hours being from 9.00 am to 5.00 pm, when most other services our service users require us to liaise or advocate with are available. In November 2006 the team spent 52% of its time in face-to-face contact with service users: this figure does not include telephone contacts, travelling time or other work carried out on behalf of service users. We will continue to ensure that at least 50% of staff time is spent in face-to-face contact with service users.