High Vulnerability High Volume FOCUS Meetings and Partnership Working Lauren Dowson Natalie Howson PC Margo Mallinson

Project Form DK

In April 2017, an event was held to develop a multi–agency response to address the needs of individuals (aged 18 and above) who are identified as repeatedly contacting and attending services in North Yorkshire (repeat attendees.) There was representation from North Yorkshire County Council, Tees Esk and Wear Valleys NHS Foundation Trust (TEWV), the police & Yorkshire Ambulance Service.

Target Progress Report DK

Target Progress Report DK

Activity Data Collection – by referral, different criteria Sarah

Activity NY Police Sarah

Ideas Market Place Knowing who the people are Triggers Response Agreement/Contract Co-Produced Plan Follow-up & Maintenance SS

Ideas Market Place

Ideas Market Place

It was agreed that the agencies should work together, using tele-conferencing and face to face meetings, to identify and manage repeat attendees so that their needs could be better met. They would be nominated to the FOCUS (Focussed On Collaborative Unmet need Solutions) group who will identify if the person is known to them and gather/provide information. They will be invited to meet with the appropriate agencies that will support them to devise a support plan to reduce their need to repeatedly contact services. This will be recorded on ‘Our Plan’.

(FOCUS) A collaborative approach from North Yorkshire Pathway Pathway on a Page Focussed On Collaborative Unmet-need Solutions (FOCUS) A collaborative approach from North Yorkshire Pathway An evolved shared care pathway that aims to: Definition Identification Response Sarah – powerpoint slide “Our Plan” Review

Multi-Agency Agreement Focussed On Collaborative Unmet need Solutions

Consent I have been identified as a person with unmet need through frequent contact to services   The service I contact most regularly will contact relevant services to share their concerns   Any relevant professionals may contact me to discuss my support needs and my wishes as to how they could be met   A meeting will be arranged to suit me within a14 day period (friend/family/advocate can be in attendance)   I will meet with relevant professionals and contribute to a support plan to meet my needs and reduce contact to services   My plan will be reviewed as I require

Consent

Our Plan

At the event various systems and processes were devised and a number of involvement groups were arranged with 3rd Sector Agencies, Service Users and Carers. The recommended some changes including scrapping the credit card idea as they personally would not carry it around but recommended completing the form instead It was also recommended we invite the service user to chose the venue that suits them and also bring an advocate and representative

Lessons Learned It was initially planned to complete the documentation at the same time as the appointment but service users did not like this Initially too many people attended/ad hoc attendees – asked for consent from service user Teleconferences did not take place Tasking meeting with Community Impact Team Sharing information with GP’s – improvement needed Involving other staff - delegating

Case Study’s LJ - attended, repeated presentations with A&E, ambulance, police, MHS, planed appropriate care for when she was discharged from prison AA – did not attend, plan still created resulting in reduction of attendances by 100% for Mental Health Services and police, prior to this multiple arrests and section 136’s and admissions CO – did not attend, plan created, still engaging with MH Services, no presentations with police JR – attended, reduction in presentations and antisocial behaviour

Information sharing RK – able to share information and concerns and organise admission CJ – attend strategy meetings MM – training sessions for Council staff HB – RCA attendance providing further information SGH – joint working – creating a space for MH Assessments