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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