1. Collaborative crisis planning Miles Rinaldi Head of Recovery & Social inclusion

2. “On an important note, the team that supports me believes fully that I have the right to decide the treatment I need and this extends to crisis. This allows me to work collaboratively with them and I trust them.”

3. NICE (2011): A crisis plan should contain: Possible early warning signs of a crisis and coping strategies Support available to help prevent hospitalisation Where the person would like to be admitted in the event of hospitalisation The practical needs of the person if they are admitted to hospital (e.g. childcare, care of other dependants, including pets) Details of advance statements and advance decisions Whether and the degree to which families or carers are involved Information about 24-hour access to services Named contacts.

4. Main types of advance statements Crisis card Advance Directive Facilitated Advance Directive Joint Crisis Plan AimSelf-advocacy Increased autonomy for person with respect to mental health care Increased consensus between person and mental health providers Involvement of mental health providers? No involvement necessary Either no involvement or indirectly through contact with the facilitator Direct involvement Adapted from Henderson et al (2008)

5. Trust audit (2012): Recovery focused care planning

6. What makes a good crisis plan? Delphi: services users, family, friends, carers and mental health professionals. 78/94 statements reached positive consensus An interesting finding.... 10% of service users 25% of carers, families and friends 49% of mental health professionals –Disagreed or strongly disagreed with the statement: ‘crisis plans will not work because services will not honour them’. …. New collaborative crisis plan and organisational standards

8. Collaborative crisis plans uploaded on RiO

9. What helps and hinders when in crisis? Thematic analysis of 50 randomly selected collaborative crisis plans developed between January – March 2015. What helps? Maintaining wellbeing (comfort, personal safety, self-management, being active, staying connected, normalisation). Importance of personalised medicine and support (access and availability of services, types of support and services, role of family). What hinders? Passivity / apathy (doing nothing, uncertainty, withdrawal from supports) Lack of autonomy (intrusiveness, lack of respect, decision-making) Pressures (work, housing, family, temptations)

10. Systems: Crisis plans Community team and GP Crisis plans inform initial HTT / ward care plans Update or develop crisis plans informed by recent crisis Home Treatment Team Inpatient Ward

11. Implementation We used Normalization Process Theory (NPT)  focuses on the work of embedding and of sustaining practices -helps in understanding why some processes seem to lead to a practice becoming normalized while others do not. Operationalized through four generative mechanisms: 1.Coherence - the meaningfulness of a collaborative crisis plan for care co- ordinators 2.Cognitive participation - engagement of care co-ordinators and service users 3.Collective action - interaction with already existing practices (Care Plans) 4.Reflexive monitoring - how the collaborative crisis plan is understood and assessed by care co-ordinators

12. Comments “We often only meet the unwell individual and do not have any “baseline”. If we have a collaborative crisis plan where we have information on what they like to do and eat, their family and friends etc., this helps us to engage the person who is unwell.” Deputy Ward Manager “I have used the collaborative crisis plan during mental health assessments. The AMHP and independent psychiatrist generally have not met the client before. If the collaborative crisis plan has been completed it can demonstrate when a client may not have reached a crisis point and a community based option can be planned.” Community Psychiatric Nurse “the nurses can quickly see what does and doesn’t work for you… the plan immediately cuts out the things that aren’t helpful and makes it possible to articulate things that you cannot articulate when in crisis.” Service User “…provides a sense of empowerment as the focus is on the positive but recognises when assistance is needed”. Community Psychiatric Nurse

13. Thank you Miles.Rinaldi@swlstg-tr.nhs.uk

14. Enhanced Primary Care Service for Mental Health Patients Sarah Garner, Newham CCG Matthew Oppong, ELFT

15. What is the service? The service will support people who: Step Down - patients who, after a period of treatment in secondary care, have become stable enough to be transferred to primary care but require support in order to make the transition. Step Up - patients who are not currently in secondary care but who, have mental health, psychological or social needs that require an enhanced level of support. These patients can access EPC service once an assessment has been completed.

16. The Background Focus more strongly on achieving service user recovery goals Provide a higher level of social and psychological support Enhance training within the team and to GP practice Monitor service performance more closely.

17. Why Redesign? Integration of service pathways A focus on recovery and support and less stigma Improved pathway working which builds on current services, partnership working and ensuring the patient is paramount Delivers a minimum set of access, waiting times, prevention, co-production and recovery standards Access should be at the lowest level required, rather than of accepted threshold or the right service – causing cracks in provision

18. Our Aims The service aims are:  To support service users to achieve their recovery goals through a process of joint planning that places the service users at the centre.  To empower people to self-manage their own recovery journey and reach a position where they can reduce their contact with mental health services.

19. Our Aims  To mark the recovery journey by recognising achievements whilst in EPC and at the point of discharge from EPC.  To improve service user experience and outcomes through enhanced multi-disciplinary team working that addresses mental health, physical health and social care need as part of an integrated approach.  To improve service user experience and outcomes through the provision of care in a normalised setting, close to home

20. Our Aims  To assist the navigation of service users towards community resources that support their recovery journey  To enable the development of capacity, confidence and competence in relation to mental health treatment and care, in the primary care workforce through the sharing of knowledge and expertise.  Ensure the best clinical processes are followed in the discharge for patients from secondary to primary care.

21. Support for GPs Patients will be reviewed, in consultation and collaboration with the GP quarterly for the first 3 quarters and by the Liaison Worker in a face to face meeting. The frequency of review meetings can be increased if there are changes in symptoms of presentations medication lapse/DNAs the absence of the GP other factors that might have an impact on clinical outcomes

22. Why this partnership? Some of the advantages of joined up partnership work Treating the person in line with the most appropriate clinical intervention A normalised environment close to home, reducing stigma and supporting recovery Continuity of care - People and their families often form important long term relationships with their MH practitioner

23. What is included? Recovery goals set by the patient Mental health Physical health Medication Healthy lifestyles (including as appropriate weight management, smoking cessation, alcohol and substance use, sexual health and dental health) Access to employment Relationships and social support Cultural needs, including where the patients’ first language is not English Relapse indicators and contingency plan Contact details of key professionals.

24. What is included? The achievement of recovery goals will be monitored in the plan and celebrated as part of the recovery journey. Patients receive acknowledgment, of their achievement from those involved in their recovery care plan at the point of discharge from EPC. Pathways for patients with SMI who have a comorbid problem with alcohol and substance misuse, sexual and dental health are currently in development.

25. What did we learn? Service redesign depends on people The right people in the room Committed to change Committed to achieving it Multiple partners with different objectives – getting that common purpose and aim Credit where credit is due!

26. Thank you!