The Team Approach, Does it Support Recovery?

1. The Team Approach, Does it Support Recovery? Rebecca West – Occupational Therapist Team Manager Rebecca.West@nyypct.nhs.uk Jane Richardson – CPN Jane.Richardson@nyypct.nhs.uk Assertive Outreach Team York & Selby North Yorkshire & York Primary Care Trust

2. Workshop Outline: • Setting the Scene: • Who are we? • How did we get here? • Key Influences • Rationale for Change: • “Frustration” • What do we do all day? • Time to reflect • Something new is needed! • What’s Next?

3. Community Outreach Team (2000 – 2004) 40 Clients 4 WTE Keyworkers 9am – 5pm Monday to Friday Assertive Outreach Team (2004 onwards) 92 Clients 10 WTE Keyworkers 8am – 8pm Mon to Fri & 9am – 5pm W-ends & Bank Holidays

4. Nursing Staff: Band Six – 4 Band Five – 1 Medical Support: Consultant Psychiatrist – 0.7 SpR – 0.6 SHO – 1 Psychologists: Clinical Psychologist - 1 Social Workers: AMHP – 1 Band Five – 2 Occupational Therapists: Manager, Band Seven – 1 Band Six – 2 Recovery Support Workers: Band Three – 4.2 Admin Support: Medical Secretary – 1 Secretary - 1 Selby & York AO Staff ComplimentMay 2009 - Clients: 92 (Capacity)

5. P.I.G. 2001 N.S.F 1999 Keys to Engagement 1998 NHS Plan 2000 York Team Established • Clear directions, “Team Approach” • Service for as long as needed. • Services to manage, contain, maintain • Focus on keeping out of hospital Full to Capacity – Waiting Lists

6. Policy Implementation Guide (2001) “the service shall support service users and his or her family for sustained periods” “treatment should be provided on a ‘long-term’ basis with an emphasis on continuity of care” “As long as there is evidence of benefit, Assertive Outreach should continue indefinitely”

7. Team Approach – Key Themes • Staff know and work with all service users. • Continuity of care is provided by the team as a whole. • The collective skills and experience of a whole team are made accessible to all clients. • Workers act together in decision making. • Shared responsibilities towards all clients. • Dependence on individual workers is reduced – staff are interchangeable. • Staff burnout is reduced.

8. 2004 Onwards • Recovery Messages: • Focus on strengths/ hopes • Maintenance is not enough • Moving on from services • Positive risk taking • Changing perspectives on the chances of recovery

9. Working Towards Recovery – A Familiar Phrase “Recovery is the personal journey of an individual, the process of rebuilding a meaningful, satisfying and valued life” (Rachel Perkins, 2002) “It involves individuals taking small, concrete steps. Setting goals and breaking down large tasks into manageable steps” (Rethink , 2004) “If we want to develop recovery orientated services we need to offer systematically, organised and personally tailored collaborative help, treatment and care in an atmosphere of hope and optimism” (Lester & Gask 2006)

10. 2008 • Services Forever vs Rehabilitation & Moving On • – unclear messages • Full Caseloads – Waiting Lists • Implications for Clients & Families • Challenges for Workers ?

11. Frustrations • Staff having too much work to do – not enough time. • Staff not applying their own “professional” skills as effectively as they would like. • Assumptions that “the team takes care of it” – things are missed. • Clients finding they are telling the same thing to lots of different workers, loss of continuity. • Staff feeling they are all performing a similar role.

12. Current model with two levels Individual staff Whole Team CC C

13. Whole Team Approach – In Our Team • Everyone can work with everyone • Allocate staff resources at a central level. • Everyone involved in decision making. • Who does what work is decided in the morning meetings.

14. The Hub Of it All! Morning Meeting 45 minutes Clients regular set appointments Cancelling client visits Tasks from team diary Hoped for admin time lost Crises Appointments not covered or shorter “pop-in” visits Tasks already in staff diaries

15. Does it Have To Be Like This?

16. Is this how everyone works?

17. Can goal orientated recovery work be best managed via a whole team approach?

18. What Do We Do All Day?

19. Work Activity Audit – March 2008 On the back of staff concerns • Too much work to do / not managing it • Staff not applying skills as effectively as would wish Data collected by all staff over a 14 day period using DASh (Daily Activity Sheet)

20. Total Time Engaged in Each Type of Work Activity:

21. Direct Client Contact – Breakdown of Activity:

22. Breakdown of Time Spent in Meetings:

23. Time Out Day April 2008 Concerns Raised: • Clinical a) Too much time spent on reactive work or ongoing support. b) Creating possible “dependence” on team. c) “Ward in the Community” (Community Institutionalisation) d) Staff felt didn’t have enough opportunity to apply their personal and professional skills to help move clients forward in a recovery focussed manner.

24. 2. Work Management a) The way we managed our work in the team was not successful. b) Work frequently exceeded resources. c) Lots of last minute cancellations and changes to visits. d) Pressure on admin tasks. e) Little time for team development Some of these were attributed to the “Whole Team Approach” way of working.

25. What Did We Want? • Allocation of work to more closely match resources • Work more effectively with recovery goals • Ensure the positive aspects of “team approach” were not jeopardised. Introduced 3rd aspect to the model “Core Team Level”

26. Proposed model with three levels Individual Staff Whole Team CC C Core teams

27. Core Team Level • An intermediate level between whole team and individual level. • It’s a balance between the other two. • Has the capacity for all various factors without any of weaknesses of the two extremes. • The core team level good enough at enough things so it can do recovery work

28. A breakdown of different several aspects of team working by level at which these may possibly be best performed Case review Expertise, consultation Crisis management Supervision Overseeing core-team business Stress monitoring, management Delivery of recovery focussed treatment approach Shared decision making Workload management Application of skills Team policy and procedure Care-coordination Flexible back-up, Consistency of approach Diary management Therapeutic relationship

29. Does the Whole Team Approach Best Support Recovery Focussed Work?

30. Diagram of work management in the proposed three level system Individual worker Direct contact/manages own diary If a need requires an immediate, priority response Core team Work & treatment management Whole team Flexible back-up, team management, specialist resources ‘The 2 shifties’ Shift management, crisis response