Best Practice When Engaging Hospitals & Community Mental Health Teams Sophie Koehne and Steffan Desscan Advanced Mental Health Practitioners KHP Pathway Homeless Team - SLaM

Outline Mental Health and Homelessness Difficulties Accessing MH Services 4 Levels of Mental Health Care Points of Access to services Onward Referrals Working with Mental Health Services KHP Pathway Homeless Team Model

Complex Health needs & Tri-morbidity Mental Health Substance Misuse > 60% history of substance misuse 70% reach criteria for personality disorder 4-5 times high rates of psychosis than housed population Physical Health >80% at least 1 health problem, 20% have more than 3 health problems

Homelessness Mental Health

Difficulties with accessing mental health services Knowing where to start Getting an assessment Lack of early intervention before crisis point Knowing when to access A&E What are your rights and duties as carers Lack of holistic approaches Lack of understanding of MH and Homelessness Not knowing the full history Busy/hurried clinicians MH Gatekeeping Knowing what to expect

4 Levels of Mental Health Care Hospital Admission Crisis Resolution Home Treatment Team (CRHTT) Community Mental Health Team (CMHT) General Practitioner (GP)

Points of access GP Non-urgent/Routine Main point of access to MH Services A&E In Crisis Out of hours emergency Police Causing a risk to themselves or others in a public place

Onward Referrals Needs specialist input CMHT GP IN CRISIS HTT/ CRT A&E Hospital Admission Police Place of Safety (s136)

Onward Referrals CMHT GP Low MH Risk Minimal MH risk HTT/ CRT A&E Medium MH Risk High MH Risk Hospital Admission Police Place of Safety (s136)

Onward Referrals CMHT Minimal MH Risk GP Low MH Risk HTT/ CRT A&E Medium MH Risk Physical Health risk Important to note that most of our referrals are not rough sleepers Outside of central London – hidden homeless and sofa surfers not picked up by traditional collection methodologies Hospital Admission Police Place of Safety (s136) High MH Risk Chaotic/Violent

Onward Referrals CMHT GP HTT/ CRT A&E Hospital Admission Police Place of Safety (s136)

What you can do to aid access to services Know your local services Have a list of contacts – build a database Support clients to attend appointments at GP / A&E Write a letter outlining concerns to GP or CMHT Knowing your client’s story…

What you can do to aid access to services Knowing your client’s story: What’s brought the client (and you) here (presenting issue)? How has their behaviour changed (symptoms)? How long have you noticed changes in behaviour (recent history)? Has this happened before (history)? What is normal behaviour for client (baseline)? What’s caused this change (triggers/stresses)? What’s worked well in the past (coping strategies)? What are your concerns if left without specialist support (risks)? Who is in their support network? What do you think they need (care plan)?

Working with Services Personalised Collaborative Care Plans Risk – shared management Holistic care - discuss strengths and goals Know what can and can’t be communicated with and without consent (confidentiality) Attend ward rounds/CPA (care planning meetings) with your clients to be involved in times of transfer of care Regular communication with services involved with clients Know your duties and limitations as carers Manage your (and clients) expectations!

KHP Pathway Homeless Team Model Prevent the revolving door Improve hospital experience Reduce unsafe discharges Improve health and housing outcomes Support to access scheduled care Reduce bed days Reduce readmission to hospital Promote Inclusion Health approach

Multidisciplinary Approach Team focus on case formulation and action planning GP- Holistic clinical review, advise support admitting team. Housing Worker - specialist housing knowledge, rotations, advocacy at housing, knowledge of services Advanced MHP – backgrounds of working with patients with complex mental health issues, knowledge of mental health services and formulation of plan for how the team will work with that patient and manage risk Notes – receive a referral comprehensive notes review and background check prior to assessment. Team discussion on referral, how best to proceed, what patient’s needs are, best placed person to assess – process led by Advanced MHP’s Team highlight any physical health issues and liaise with GP – holistic health screening, liaison with admitting team regarding health needs Each case will have input from entire team. Each case is discussed on a regular basis and how the team works and liaison with wards and services carefully planned. Housing Worker will advise on potential housing options, liaison with homelessness services. When preparing a housing case - summary of needs prepared by MHP’s, supporting letter from GP. Housing Worker’s rotate between sites, each have different background and experience in working with homeless people and knowledge of housing law Provide advocacy and support at Housing appointments with clients. Sometimes housing worker and MHP will attend assessments with patients depending on their needs. The MHP role in team important in overseeing and planning the day to day running of the team, leading on complex cases and liaising with community teams.the team is an inpatient service but main focus is on the needs of the patient upon discharge. MHP identify areas of support – referrals needed.  

Multidisciplinary Approach Flexible approach – Bridging the Gap Interventions as an inpatient Specialist knowledge and networks to support in patient wards Support post discharge Handover and support to community teams and services What that means for the patients Flexible working approach   Team work with patients who do not have care coordinator when admitted Patient may not have met their community team prior to being discharged. Support Wards around referral to appropriate community team. Follow up with patients in community, handover to care coordinators.

Interventions Care Coordinator Advice Staff Training Holistic Needs Assessment & Risk Assessment Liaison with Services Reconnection Housing support Community health follow up Practical assistance GP review & liaison Staff Training Advocacy Challenging practice Care Coordinator Advice Information gathering Frequent Attender Work Identifying ‘missing’ persons Community Access

Services we work with Wards Reablement Team (Southwark) START Team Southwark Law Centre  Bed management meetings Local authority Housing Departments  St Mungos, The Passage, St Giles  GP surgeries  Street Outreach teams Hostels Place of Safety Non-local authority housing providers  CMHTs Health Inclusion Team (HIT)  No Recourse Teams Hospital Social Work teams (Lambeth & Lewisham) KHP Teams at Kings and GSTT  Routes Home  Night Shelters Home Office / Immigration services / Embassies Welfare teams – for benefits advice and support Department of Work and Pensions Police –Probation OT department Solicitors Homeless Day centres HIV Liaison Team Other Mental Health Trusts  Wellbeing Hubs Solidarity in a Crisis  Interpreter services Food banks  

What we achieved Outcome No. (from 237 caseworked)   Spreadsheet data: 465 referrals and 237 seen and caseworked by team between Feb 2015-Dec 2017: Outcome No. (from 237 caseworked) Improved Housing status 171(72%) Eviction/housing loss prevented 25 (11%) Local Authority ‘homeless application’ 57 (24%) Referral to supported accommodation 67 (28%) Reconnection offered (nationally or internationally) 61 (30%) No Recourse to Public Funds 24% Local connection - This indicates a high level of transience and historic GP connection as well as the importance of identifying patients who can be reconnected outside of the SLaM boroughs Patients admitted to SLaM based on GP, however GP does not always correlate to housing connection Audit early on in service showed high levels of HIV, younger population. Medical comorbidity

Summary Mental Health is complicated. Mental Health services are even more complicated! Being homeless or socially excluded adds further complexity! Real role for homelessness professionals to advocate and educate for our client group Multidisciplinary and multi-agency working is vital to support the needs of this client group

Multi-agency and Multidisciplinary KHPHomelessTeam@slam.nhs.uk

Any Questions??? Sophie Koehne – sophie.koehne@slam.nhs.uk Steffan Desscan – steffan.desscan@slam.nhs.uk Khphomelessteam@slam.nhs.uk