Download Early Intervention - your care your way

Bath and North East Somerset
Community Health and Care
Services:
Early Intervention Psychosis
SD56
1.
Introduction
B&NES has been reshaping its Mental Health Service incrementally and engaging with both
the community and professionals to identify where change needs to take place.
In addition to consultation and engagement in relation to future service provision, best
practice and national guidance and policy prescribes certain service requirements, not least
of all for EIP services. These are described at section 3. Most recently, the Early
Intervention in Psychosis Programme, has been assessing readiness to meet prescribed
targets within NHS England wait times for first episode psychosis et al mental health service
targets.
2.
Purpose
The purpose of community mental health services is as detailed in the overarching
community mental health services specification, which should be referred to in conjunction
with this service specific specification.
3.
Aims & Objectives
The EIPS will achieve these aims by working towards the following objectives:
 The length of time young people remain undiagnosed and untreated is a service
median of <3 months and an individual maximum of <6 months.
 Effective early assessment, treatment and recovery focussed interventions.
 Delivering high quality, outcome-focused and evidence-based services that are cost
effective.
 Minimise the frequency and length of stay of hospital admissions for people who need
it, by working in partnership with the Home Treatment Team to offer alternative means
of support and treatment.
 Reducing the stigma associated with psychosis by taking part in improving
general community awareness of symptoms and the need for prompt
assessment.
 Providing socially inclusive activities that raise self-esteem and promote personal
development.
 Promoting meaningful engagement with service users, their families and others as
appropriate to ensure collaboration in the planning, delivery and monitoring of
services they receive.
 Ensuring that carers have access to an independent assessment of their needs.
 Ensuring continuity of care for service users by networking effectively across primary
and secondary care and reducing barriers to inter-agency working.
 Promoting rapid access to the EIPS by maintaining effective partnership working with
stakeholders and other agencies
4.
Policy context
The following documents have informed the development of this service
specification:
Over the past decade there have been numerous national policy drivers in relation
to mental health including: The National Service Framework for Mental Health (1999);
Followed by the NHS Plan published in 2000 which demonstrated a commitment
towards Early Intervention in Psychosis (EIP). The Policy Implementation Guidelines from
the Department of Health were published to guide the development of EIP services
nationwide.
Early Intervention receives a high profile throughout New Horizons: towards a shared
vision for mental health (2009), acknowledging its success in treating psychosis in young
people. It highlights the greater focus needed particularly for adolescents especially at
the interface with adult services. It suggests improving service models and service
delivery. New Horizons recommends early intervention as an approach which might be
applied to other illnesses but this is not to suggest that Early Intervention in Psychosis
Teams should take these on, nor that the age range should be expanded beyond the
current 14-35.
More recently No Health Without Mental Health (2011) has been published by the
Department of Health. We would expect the provider of mental health early intervention in
psychosis services to be fully conversant with these documents and other relevant
documents as well as future ones as they are published.
The EIPS work within the World Health Organisation’s definition of Psychosis:1 ‘Psychosis’
is a set of symptoms that can be evident in a range of mental health problems, including
those diagnosed as ‘manic depressive psychosis’, ‘bipolar affective disorder,’
‘schizophrenia’ and ‘paranoid schizophrenia’. The term refers to a disturbance in a
person’s thinking that divorces them from their surrounding reality. This disturbance is
often manifested in distorted perceptions (hallucinations), delusional (paranoid, grandiose
and depressive) ideas, disorganised speech patterns, and intense mood fluctuations.
First episode psychosis refers to the first time a person experiences either psychotic
symptoms or a psychotic episode.
Recent prediction model of incidence of first episode of psychosis by Kirkbride et al 2012
has been developed to support the commissioning of EI Services. This model predicts the
incidence for 16 – 35 age range in each local authority area. (www.psymaptic.org ).
Current NICE Guidance:

NICE Guidance [CG178] February 2014 Psychosis and Schizophrenia in adult:
treatment and management.

NICE Guidance [CG155] January 2013 Psychosis and Schizophrenia in children and
young people: recognition and management.

Quality Standards for Psychosis and Schizophrenia in adults are scheduled for
February 2015.

Psychosis with co-existing substance misuse CG120 March 2011 is scheduled for
revision in 2015.
5.
Service Delivery
5.1 Service Model
Early Intervention in Psychosis Services (EIPS) provide assessment and care for
individuals experiencing a first onset of psychosis, usually under the age of 35.
Characteristically they focus on optimising control and reducing the distress of psychotic
symptoms, providing a range of psychological, family and social interventions and
assisting in the personal adjustments arising from the experience of a first episode of
psychosis. EIPS works with an individual for up to three years during the ‘critical period’ to
maximise the chances of a symptom and social recovery and is provided by a
Multidisciplinary Team.
The EIPS recognises the vital importance of close partnership working to meet the
needs of people using the services to achieve socially inclusive outcomes and to ensure
effective safeguarding practice.
The EIPS will be provided through close collaboration with partners in primary care
teams, the Local Authority’s adult and community services, Education and Housing
services Voluntary Sector organisations and other specialist mental health teams. The
team will work closely with other appropriate professionals, teams and support services
as required, including crisis resolution and home treatment teams, assertive outreach,
community mental health teams and substance misuse services, voluntary
organisations, in-patient services and private and independent hospitals. EIPS will work
in partnership to deliver a seamless service and holistic care plans for service users.
2.1 Aims and objectives of service
Aims
2.1.1 To provide high quality early intervention in psychosis through:
Early identification, assessment, treatment and support for individuals who experience a first
episode of psychosis.
The service will provide proactive therapeutic engagement and interventions to reduce the
impact of psychosis:
 Maintaining the median duration of untreated psychosis at under 3 months (this
related to individuals who are not engaged in any form of intervention not just
medication)
 Provide comprehensive community services, reducing the impact of hospital
admission and managing symptoms.
 Improving the client’s social functioning (especially their employment and
employability, quality of life and satisfaction with the service)
 Assisting with their recovery and aspirations.
The EIPS will meet service users’ social and mental health needs in ways that respect
age, culture, gender, individual difference and choice, and enable them to maintain their
place in their local community and achieve their full potential.
The EIPS will minimise the distress and impact caused by psychosis using approaches that
draw on evidence based practice and positive outcomes. The service will encourage people
to take a full part in the treatment they receive whenever practically possible, and provide
this in the least stigmatising, coercive and restrictive environments available.
The EIPS will meet the objectives set out in the Mental Health Policy Implementation Guide
(1999) and be consistent with the IRIS Guidelines Update (2012)
2.2 Service description/care pathway
The purpose of the Early Intervention in Psychosis Service is to provide high-quality holistic
care in accordance with current research and best practice guidelines.
Services will be provided on the basis that each person using the service is an individual,
with their own strengths, needs, life experiences, beliefs, aspirations, friendship and support
networks. Therefore to establish an effective therapeutic relationship, the service will need to
be person centred and outcome focussed. They should avoid making assumptions or taking
a one size fits all approach when considering how they engage with individuals or how
support is offered or delivered.
This approach supplements the often more obvious considerations in regard to gender, race
disability or sexuality and will an organisational culture and support to ensure that staff have
the appropriate training, attitude and approach towards the people they are working with. The
person has to be at the centre of everything the service does rather than the other way
around.
The EIP service in Bristol maintains a unique position in embracing clients of Child and
Adolescent Mental health Services (CAMHS) and Adult services. The position of this service
is intended to capture a client group that historically could get lost in the transfer between
these services.
The service will develop a training and health promotion function and will target key partners
with the aim of developing the capability for early recognition of young people requiring
support. To include colleagues in Primary Care, Education, Housing and Social Care.
The key components of the service are:
2.2.1 Making services accessible
Providers will actively consider how their service will respond to the needs of each CCG’s
diverse population. This will include complying with relevant equalities legislation and best
practice guidance. We will expect the service to make reasonable adjustments to ensure
the service is open and accessible to the whole of our population.
Particular reference will be made to needs of people with disabilities, people from black and
other ethnic minority communities or those people who currently find it difficult to access
current services or are under-represented within those services.
There is a specific expectation that people with a learning disability will not be excluded from
the services offered and that reasonable adjustments will be made to ensure an inclusive
service delivery model.
The service will be delivered in line with the requirements of the national and local autism
strategy to ensure people with autism have access to mainstream public services where
ever possible and in doing so will be treated fairly as individuals.
2.2.2 Assessment
The service will ensure prompt assessment in line with response time and prioritisation as
set out in this section 2.6 of this specification to reduce treatment delay.
Assessment is a complex process which also encompasses the initial engagement of the
individual and where possible their family. The service ‘embraces diagnostic uncertainty’ and
the full assessment may take place over a three month period if time is needed to establish
the most helpful service to be involved. Assessment is then a continuing process and
influences interventions at different times during the period of treatment.
The assessment will:
Be in a setting is as comfortable as possible for the individual and their family.
Clarify the individuals concerns and also the concerns of their family, friends, GP,
teachers, lecturers etc.
Provide a comprehensive assessment of the presenting history and seek to
clarify whether the presenting problems are related to first episode psychosis.
Include an assessment of current mental state.
Include an assessment of risk and safety.
Assess any changes in social, occupational functioning and quality of life.
Look at the individuals aspirations and take them into account.
Assess current engagement occupation or education so as to act swiftly should
action need to be taken to maintain this and also to get early information on
potential goals.
Where family members / partners / friends are undertaking a caring role they will be
offered a separate assessment of their needs.
Physical Health and wellbeing will be assessed and baseline information
gathered. This may include blood tests and neuro imaging if appropriate. It will
also include consideration of sexual health and advice on an individual basis.
Full assessments will be completed within twelve weeks. This may be extended in the
minority of cases where there is uncertainty following this period.
2.2.3 Engagement
The provider will ensure there is an effective model for early engagement by service users. I
A creative and proactive approach will be required to suit a particular individual / family.
Supportive and empathetic relationships, working with individual strengths, aspirations,
priorities and needs are likely to characterise this.
2.2.4 Diagnosis
The EIPS will work promptly with partners to offer a specialist diagnosis of the mental health
problem the user is experiencing.
It is expected that in the early stages of engagement and treatment working within the
framework of first episode psychosis rather than a specific diagnosis is the norm.
2.2.5 Care Coordination and Care Programme Approach (CPA)
The Care Programme Approach (CPA) will underpin service delivery.
All service users taken onto the early intervention caseload (or who are having an
extended period of assessment) will have a care coordinator allocated.
The care co-ordinator will engage with and develop a rapport with the client, family,
carers and their support network. All parties involved in receiving and delivering care
will be regarded as equal partners in the process.
The care coordinator will develop a care plan that is based on Early Intervention
principles and explicitly discussed the management of any risks.
The care coordinator is the consistent point of contact but other team members will
also actively work with a service user and their family alongside the care coordinator
when needed.
The progress of service users and the effectiveness of care programmes will be
reviewed at not less than 6-monthly intervals, within a CPA framework in line with
national guidance and best practice.
Reviews will be service user and family focussed.
Reviews will take place in the least stigmatising environment in line with the service
users wishes
Reviews may be held more frequently than 6-monthly if required, by agreement with
the service user and family.
Reviews will focus on care planning and provision to meet the needs of the service
user and family.
2.2.6 Treatment and Interventions
Wherever possible the approach to treatment and intervention is collaborative. The service
user and family will be provided with up to date, evidence based information in a way that s
will help them make decisions about the available options.
The overall aim of the 3 year programme is to build resilience in the management of
symptoms and support the integration of elements that comprise an ‘ordinary life’.
During the 3 years with the EIPS, interventions may include:
An early response to a mental health crisis which will include intensive support to
reduce the need for hospital admission
Admission to inpatient facilities when required
Prescribing, monitoring and review of antipsychotic and other medication at the
lowest effective dose. Any negative impact of antipsychotic medication (such as
weight gain) will be taken into account with the service user and their family.
Psychosocial interventions provided as part of the care coordination.
Understanding of the build up to the psychotic episode and the development of a
relapse management plan.
 Interventions that give opportunities to access a range of activities that build / re-build
confidence.
Support to regain a sense of social agency and integration and access social
activities.
Proactive support to gain or regain employment or education
Cognitive Behavioural Therapy (CBT)
Family support and interventions.
Health promotion
Proactive assessment and monitoring of physical health
The service user and family will be involved in decision making processes regarding any
agreed treatment or intervention and be informed of their possible adverse effects.
To ensure that medication prescribing is in line with National Institute for Clinical Excellence
(NICE) guidance, low dose atypical neuroleptic medication will be offered as first line
treatment, together with providing information and monitoring of adverse effects to enhance
concordance.
2.2.7 Discharge processes
At the Care Plan Meeting six months prior to the 3 year term, there will be a review of next
steps. For those service users who need further input from mental health services the process
of transition / transfer will then be considered and a pathway mapped out which may include a
period of joint working.
Early discharge will be considered for service users who have reached a period of stability;
are functioning well and will have a direct route of entry to the team for 3 years of EIP
involvement to prevent relapse.
Late discharge – for some clients with higher needs the 3 years discharge may come at a
crucial time in their life e.g. birth of a child, housing move, admission to specialist unit where it
may seem inappropriate to add to their stress with a transition to a new service.
If the EIP approach is not meeting service user’s needs within the 3 years then clear referral
pathways will be in place to support early discharge to the more appropriate services e.g.
rehabilitation services
2.3 Care Clusters
Alongside the CPA process the service will use the Care Cluster model in line with locally
agreed payment by results cluster arrangements with Commissioners.
All service users will have their needs identified following which they will be allocated to a
provisional super cluster assigned to them. A super cluster will be one of the following:
Organic (will be directed to specialist organic services)
Non Psychotic
Psychoses
Each service user will have their needs allocated to a care cluster and specific care
packages will be offered according to each cluster. Each cluster will have its own
specific review period but as a minimum, each review will be undertaken following
assessment, at each CPA review, and at points when needs change significantly.
There will be regular re-assessment/re-cluster and CPA review in line with national and
local clinical guidelines and a clinical decision made as to whether the service user will step
up, or step down within or outside of the service.
2.4 Provision of Information and Training
The team will offer education, training and supervision for partner organisations to assist
them with concerns regarding possible psychosis. EIPS will deliver awareness sessions
about early psychosis, its detection and management to stakeholders and partner agencies
Every Service User and their carer will be provided an information / welcome pack when
they are taken onto the EIPS caseload in the Service Users first language containing
information about the EIPS and included other Trust guidance.
2.5 Days/Hours of Operation
The core hours for contacting the service are Monday to Friday 9.00 am to 5.00 pm but the
team work flexibly beyond these hours to address individual needs.
The EI Team works closely with the Crisis Team to provide a more intensive 24 hour support
when needed.
2.6 Referral, Response time and prioritisation
The majority of referrals to EIPS are made by GP’s. The service will accept referrals from
any source and work with them to provide the most effective response.
The EIPS can respond to referrals within 5 working days of referral.
The service will work closely with the crisis and assessment team to address urgent referrals
and agree emergency response or initial assessment processes.
The EIPS will carry out joint assessments with other community mental health teams where it
is identified in the service users’ best interests and clinically appropriate.
In December 2014, NHS England produced a new technical definition for people
experiencing first episode psychosis. This requires more than 50% will be referred
and treated with a NICE approved care package within two weeks. This is a change for
the EI services who have been working for routine assessments within 4 weeks of
referral. Each EI team within the service will need to produce baseline data regarding
waiting times from referral to treatment. The locality managers with the Commissioning
CCG will validate this and develop a service improvement plan as required if waiting
times are in excess of 2 weeks for 50% of the cohort. Service improvement plans will be
submitted to the CSU and monitored at local contract meetings. This data will be
required during 2015/16 by the CCGs on a quarterly basis as part of the technical
definitions data returns to NHS England.
E.H.4: Percentage of people experiencing a first episode of psychosis treated with
a NICE approved care package within two weeks of referral1 DEFINITIONS
Detailed Descriptor:
Indicator in development, a further update will be published when a definition is confirmed.
ACCOUNTABILITY
What success looks like, Direction, Milestones:
The measure of success will be that more than 50% of people experiencing a first episode
of psychosis will be treated with a NICE approved care package within two weeks of
referral. Monitoring has occurred from April 2015 with the expectation that the target will be
consistently maintained.
Rationale:
The NHS Mandate set out the requirement for NHS England to work with the Department
of Health and other stakeholders to develop a range of costed options in order to
implement mental health access standards starting from April 2015. Achieving Better
Access to Mental Health Services by 2020 stated that for early intervention services this
would mean that more than 50% of people experiencing a first episode of psychosis would
be treated with a NICE approved care package within two weeks of referral by April 2016.
6.
Service Development - Opportunities and Issues to be
addressed
7.
Whole System Relationships
8.
Interdependencies and Other Service
10