Manchester Assertive Outreach

What Does The Service Look Like?

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

POST	NORTH	CENTRAL	SOUTH
Team Manager	1	1	1
Community Mental Health Nurse	3	4	4
Support Time & Recovery Worker	2	2	2
Occupational Therapist	1	1.5	1
Social Worker	3	3	2
Clinical Psychologist	2
Consultant Psychiatrist	0.5	1	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.

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.

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 Tme and Recovery workers and specialist housing and welfare rights workers.

Referrals

We take referrals from the community mental health teams based across Manchester. 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 over 18 years of age.

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.

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       Manchester MInd's track record: many service users who have disengaged from mainstream psychiatric services have continued to use Manchester Mind services. The relationship of assertive outreach with other Manchester Mind 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 9am to 5pm including weekends and bank holidays.