Assertive Outreach Birmingham and Solihull Mental Health NHS Foundation Trust

1. Assertive OutreachBirmingham and Solihull Mental Health NHS Foundation Trust Dr Morna Gillespie Clinical Psychologist BSMHFT Assertive Outreach Programme Advisor morna.gillespie@bsmhft.nhs.uk

2. Overview • Background to Assertive Outreach • Evidence base • Who is the service for? • What is it intended to achieve? • Key components • AO in BSMHFT • Staffing • Interventions • Outcome measures • Meetings • Exiting

3. Background • National • “Keys to Engagement” study (Sainsbury Centre for Mental Health (1998) • National Service Framework for Mental Health (DoH, 1999) • NHS plan (Secretary of State for Health, 2000) – 220 teams • Local • First team set up over ten years ago • BSMHFT has 8 AOTs

4. Evidence Base • Service users receiving Assertive Community Treatment when compared with standard community care: • Increased contact with services • Fewer admissions and less time spent in hospital • More likely to be living independently • More likely to be employed • More satisfied with care Marshall & Lockwood (2001)

5. Evidence Base (continued) • Pan-London study found no significant difference in bed use, clinical or social outcomes when comparing AOTs with standard community care • AOT service users were better engaged and more satisfied with their care (Killaspy et al, 2006) • Other UK studies have found a decrease in admissions and bed days and improved engagement (e.g. Meaden et al, 2004, Wane et al, 2007)

6. Who is the service for?(DoH, 2001) • Adults aged between 18 and 65 with the following: • A severe and persistent mental disorder (schizophrenia, major affective disorder) associated with a high level of disability • History of high use of inpatient or intensive home based care (e.g. more than two admissions or more than six months inpatient care in the past two years) • Difficulty in maintaining lasting and consenting contact with services • Multiple, complex needs including a number of the following: • History of violence of persistent offending • Significant risk of persistent self-harm or neglect • Poor response to previous treatment • Dual diagnosis of substance misuse and serious mental illness • Detained under Mental Health Act (1983) on at least one occasion in the past two years • Unstable accommodation or homelessness

7. What is the service intended to achieve? (DoH, 2001) • Improve engagement • Reduce hospital admission • Reduce length of stay when hospitalisation is required • Increase stability in the lives of service users and their carers/family • Improve social functioning • Be cost effective

8. Key components(Hemming, Morgan & O’Halloran, 1999) • 1:10 ratio of care co-ordinator to service users • Multi-disciplinary mix of staff who operate using a team approach • Team should meet the basic needs of service users and include assistance with practical everyday tasks • Develop trusting working relationships with individual service users • Services should be ongoing and not time-limited • Offer specific evidence-based interventions • AOTs should be properly integrated into a wider system of comprehensive mental health care • Provide community based crisis intervention or have access and established links to crisis intervention services

9. BSMHFT • Functional teams • Community Mental Health teams • Early Intervention • Rehabilitation and Recovery • Home Treatment • Assertive Outreach

10. Staffing • Nurses • Social workers • Occupational Therapists • Support workers • Psychologists • Psychiatrists There should also be skills in: • Housing • Benefits • Substance misuse • Employment

11. Interventions • Service users visited at least once a week • Interventions offered: • Assessment of needs e.g. social, psychological, occupational, physical, risk, etc • Engagement • Psychoeducation • Relapse Prevention & Advance Directives • Family work and carer support • Psychology • Occupational Therapy • Daily living skills

12. Interventions (cont’d) • Social support e.g. activities • Medication • Support with housing & benefits • Monitoring and support with physical health • Support accessing education, training, employment and meaningful activities • Crisis intervention e.g. Home Treatment, Respite • Inpatient care • Substance misuse (Compass worker)

13. Outcome measures • FACE • NICE guidelines for schizophrenia • Engagement measure (Hall et al, 2001) • Admissions, bed days • Client satisfaction • Carer satisfaction

14. Meetings • Team • Daily handover • Weekly multi-disciplinary team meeting • Weekly team education slot • Annual away days • Service user • Care Programme Approach (CPA) reviews (at least every six months) • Annual physical health check • Annual carer’s assessment • Weekly ward rounds (if in-patient)

15. Exiting • Aim to move on 5-10% each year • Essential factors • Mental health stable and no significant risk / or risk managed • No admissions over past two years • Reasonably well engaged • Stable accommodation The new team should be able to maintain the above factors • Desirable factors • Improved quality of life • Good social support network • Involved in meaningful activity • Compliant with medication • Insight into mental health problems e.g. triggers, early warning signs, coping strategies