Assertive Outreach Teams [61]

Who Is The Service For?

Adults aged between 18 and approximately 65 with the following:

• A severe and persistent mental disorder (e.g. schizophrenia, major affective disorders) associated with a high level of disability.
• A history of high use of inpatient or intensive home based care (for example, more than two admissions or more than 6 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 or 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 2 yrs
• Unstable accommodation or homelessness

What is the Service Intended to Achieve?

Within any population there is a small number of people with severe mental health problems with complex needs who have difficulty engaging with services and often require repeat admission to hospital.

Assertive outreach (or 'PACT' - Program of Assertive Community Treatment) has been shown to be an effective approach to the management of these people. Using an assertive outreach approach can:

• Improve engagement
• Reduce hospital admissions
• 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.

The Service Should Be Able To:

• Develop meaningful engagement with service users, provide evidence-based interventions and promote recovery
• Increase stability within the service users' lives, facilitate personal growth and provide opportunities for personal fulfillment
• Provide a service that is sensitive and responsive to service users' cultural, religious and gender needs
• Support the service user and his/her family/carers for sustained periods
• Promote effective interagency working
• Ensure effective risk assessment and management

Evidence indicates that the following principles of care are important:

• Self-contained team responsible for providing the full range of interventions
• A single responsible medical officer who is an active member of the team
• Treatment provided on a long-term basis with an emphasis on continuity of care
• Majority of services delivered in community
• Emphasis on maintaining contact with service users and building relationships
• Care co-ordination provided by the assertive outreach team
• Small caseload - no more than 12 service users per member of staff

Hours of Operation

• Working hours: 8am to 8pm seven days a week
• Out of hours: one member of staff on call for phone advice. No provision for home visits. If visit required, referral to crisis resolution/home treatment team

Referrals

• Assertive outreach should accept direct referrals for assessment from primary care, community mental health teams, early intervention teams, continuing care teams, forensic services.
• Links should be established with local homeless service, police and voluntary agencies so direct referrals for assessment can easily be made.

Risk Assessment and Policy on Violence

• Each team should have a written policy outlining the level of risk the team is able to manage.
• Operational policy should explicitly address staff safety

Staff training should include:

• Principles of the service, cultural, gender and anti-racist training
• Skills in delivering all of the interventions listed above
• Team building, colleague support and working within a team framework
• Medication - storage, administration, legal issues, concordance training, side effects
• Use of Mental Health Act and alternatives to hospital treatment
• Engaging and interacting with other services
• Benefits to service user and family/carers of an assertive outreach approach
• Suicide awareness and prevention techniques

The training period is likely to take about 4 weeks. During the initial stages of establishing the service, the caseload should be increased gradually.

Service User Information

Service users and their family/carers should be provided with the following information:

• Description of the service, range of interventions provided and what to expect
• Name and contact of care coordinator and other relevant members of the team
• Contact details for out of hours advice and help
• Information about assertive outreach approach and benefits of maintaining regular contact
• Care plan and comprehensive information about medication
• Relapse prevention and crisis plan
• How to express views on the service

Continual Service Improvement

Regular audit of the service should be undertaken to ensure that gaps in service provision are filled. Audit should always include feedback from service users and their family/carers.