CRISIS MANAGEMENT AT THE MANAGED CLINICAL NETWORK

1. CRISIS MANAGEMENTAT THEMANAGED CLINICAL NETWORK

2. Aims • Outline crisis management ‘framework’ at MCN • Highlight contributing factors in developing a shared understanding • Outline evaluation project

3. Service Criteria • Diagnosis of personality disorder or identified personality difficulties • Multiple ‘complex’ needs • Significant risk, particularly to self • Poor response to previous treatment • Limited social network • Difficulty maintaining contact with services • 18 and above

4. MCN Care Co-ordination • Up to 100 weeks clinical case management • Small case loads • Assertive approach • ‘Intensity’ titrated to stage of treatment • Safety & Containment • Control & Regulation • (A Simpson, C Miller & L Bowers, Journal of Psychiatric and mental Health Nursing, 2003)

5. Service User Involvement 3rd Sector Parties Family & Carers Individual Psychology/ Psychotherapy Accommodation Care Co-ordinator & Service User Group Work Programmes Occupational Therapy Inpatient Teams HCSW Support Pharmacy Input Crisis Resolution home treatment team

6. Key Challenges • Significant number of inpatient admissions • Significant degree contact CRHT team & police (S136) • How to manage ‘splitting’ across services • How to embed ‘general therapeutic strategies’ • How to balance immediate safety with treatment goals

7. Crisis Management Framework • Principle: ‘Relief comes from having a connection with someone who understands’ • Goals • Support service user to ‘contain’ distress • Prevent an escalation • Support service user to return to the previous level of functioning as quickly as possible • Respond in a way informed by a formulation • Avoid a service response which escalates distress or reinforces maladaptive behaviours • Therapeutic Stance • Align with the patient’s distress • ‘Containing’ Interventions • Convey support and understanding • Establish a connection with the service user • Focus on affect rather than content • Use straightforward, concrete statements that reflect an understanding of the current situation and the patients’ experience • Reinforce the service users strengths and self-management skills • Set limits supportively • Arrange additional support (e.g. MCN team, CRHT) • (Practical Management of Personality Disorder – John Livesley 2003)

8. Crisis Plan Template

9. A Shared Approach, What Helps? • Crisis plan framework • Formulation informed crisis plans • Crisis plan developed with service user and key ‘partners’ • Guidance for admissions incorporated into CPA care plans • Practice development lead role • Consultation • KUF training • ‘Specialist’ services • Development of ‘whole systems pathway’

10. WHOLE SYSTEMS PATHWAY Service user firstpoint of contact in a potential crisis:- PDCN, CRHT, DSHT, A&E Assess risk - Refer to current FACE risk assessment and CPA crisis management plan What does the service user want: Relief from distress Offer immediate containing interventions Risk remains unacceptably High • Try other treatment options: • Involve family/carers • Increase visits • Use alternative community services – Dial House, Connect etc Contact CRHT triage Initiate joint assessment whenever possible Risk remains unacceptably high Home treatment ACS Risk remains unacceptably High Clinical reviews with Network Coordinator should take place within 48 hours of admission wherever possible Hospital admission Ward interventions should provide safety, structure, consistency and increased contact/input Refer to CPA care plan if appropriate Discharge planning to involve care co-ordinator, ward team and service user

11. Crisis Plan Evaluation • Project team; • Mike Pearce, Practice Development Lead • Vicky Green, Care Co-ordinator • Vicky Baldwin, Education & Practice Consultant • Jamie Scott, Clinical Team Manager • Project Aim • To evaluate the impact of the development of collaborative crisis plans between Crisis Resolution Home Treatment (CRHT) & Personality Disorder Clinical Network (PDCN) staff and service users currently engaged in care co-ordination at the PDCN. • change in service user’s self assessed capacity to manage ‘crisis’ effectively • change in service user’s experience of PDCN & CRHT teams in responding to ‘crisis’ • change in staff’s self –assessed knowledge, attitudes and skills • change in amount and type of contact with ‘out of hours’ services • Inclusion criteria • All service users engaged in the care co-ordination intervention (September 2011) (sample size 20)

12. Process

13. ‘When written in Chinese, the word CRISIS composed of two characters, one represents danger, the other opportunity’ • John F Kennedy • Any Questions?