Health & Adult Care Scrutiny Panel 25 April 2017 Mental Health & Dementia Services
Presenters Martin Reynolds Head of Mental Health and Learning Disability John Morgan Head of Prevention & Care Management Dr. Nevil Cheesman Clinical Director, Cognitive Impairment & Dementia Service (CIDS), WLMHT
Mental Health Social Work Service • Council managed service since January 2016 – most staff located in Civic Centre since December 2016 • Supports residents of working age with mental health problems who have social care needs or where need for prevention • Co-ordinated not integrated service – with West London Mental Health NHS Trust and other partner agencies • Focus is shifting from providing care for a relatively small number of people with high level complex needs to one centred on improving wellbeing for all
Service Structure • Mental Health Support, Wellbeing & Prevention (SWAP) Team o 16 staff including manager and two deputies o Works in community / development linking individuals with social networks & primary care with a focus on safeguarding, prevention and building community resilience. • Mental Health Wellbeing, Recovery & Placements (WRAP) Team o 14 staff including manager, two deputies and three AMHPs o Focus on safeguarding, personalisation and work with longer term service users but encompassing hospital discharge, placement finding, placement reviews, forensic social work and the Approved Mental Health Professional (AMHP) service
Community Development / Outreach & Prevention • Cranford Stronger Together Project & Social Mapping • Is it possible to alter social connections & networks? • If yes, is wellbeing improved? • Does this result in a reduction in service use? • Hounslow Wellbeing Network & Hestia • Connecting People Model
Community Hubs – One Stop Shop • Informal Community Hub and Satellite Hubs • A safe space for people with mental health issues however small • Relationship-based Social Work • Developing links with WLMHT clinicians • Adult Social Care & Mental Health o Montague Hall o The Hub on the Meadows Estate Pilot
Mental Health Prevention Pilot Local Authority has a statutory responsibility to promote prevention under Care Act 2014 � Ignore National Eligibility Criteria (Care Act 2014) � Build community resilience and increase social capital – asset- based approach - through o Co-production with service users / families / carers o Reducing isolation – help establish networks o Promoting inclusion and counteract stigma and discrimination o Promoting economic wellbeing and healthy active lifestyle o Keeping people safe
Cognitive Impairment & Dementia Service • The Cognitive Impairment and Dementia Service (CIDS) based in WLMHT is a team of experienced and specially trained health professionals who help people living with a diagnosis of dementia or who are worried they may have dementia. • The team is based at Lakeside Mental Health Unit and provides assessment and treatment for people over 18. • There are no Social Workers in the team but each locality as well as the social work team at the West Middlesex University Hospital are linked with CIDS.
Who are the team members in CIDS and what do they do? Community Psychiatric Nurses (CPN) - trained nurses with specialist • knowledge of dementia, who often complete the first assessment and provide support especially when new difficulties arise. Community Support Workers (CSW) - work with team members and • patients to provide extra one to one help as needed. Occupational Therapists (OT) - have a key role in supporting people • with remaining safe, independent and as active as possible. Psychiatrists - doctors who diagnose dementia and have an expert • understanding of how dementia and other health conditions affect people. Clinical Psychologists - help in the assessment before diagnosis and • support people (patients and carers) in talking through any difficulties they may have.
CIDS and links to the Locality Teams London Borough of Hounslow has five locality teams of Social Workers and • social work assistants aligned to the five GP clusters in Hounslow and each is linked with CIDS. The teams are mainly for residents who are older and frail, those with multiple • long term conditions, sensory impairment and for people with dementias from all age groups. Each locality has a staff member linked with CIDS and one team manager leads • on dementia and are the main link for contact with CIDS; attending the six weekly meetings with key staff. These meetings held with CIDS and locality teams are to discuss complex • cases and agree operational issues and feedback on joint work, joint visits and plan cases. Complex cases are also discussed in MDT meetings with GPs/Health • professionals to ensure a well-co-ordinated approach. We also have one AMHP based at the West Middlesex University Hospital who • is linked with CIDS and who also attends the regular meetings with them to pick up more complex cases ensuring that other options are explored to keep people safe in the community rather than rely on long term care.
Hounslow and Richmond Community Healthcare & Dementia HRCH have a Dementia trainer (one of our experienced Community Matrons) a • resource collection on the HRCH intranet, an online toolkit and e-learning programme, a Director lead and Operational lead for dementia. They ensure that our staff in the inpatient unit are prepared and supported to • work with adults with dementia alongside any co-morbidities. At a tactical level, the dementia specialists present at conferences, seminars • and other learning events and take opportunities to raise awareness in the community. Operationally, they undertake clinical interventions in partnership with other • HRCH practitioners, particularly at the point of referral to the service and at discharge and at any other point when specialist knowledge adds value. The dementia specialists receive referrals from Community Matrons, • Community Nurses, GPs, Hospitals, Physiotherapists, Occupational Therapists, Rehab team, Patients themselves, Social Care Teams, and other Specialist Community Health Workers. Many referrals are requests to support other clinicians when a patient has challenging behaviour and they or the family can’t carry out the care required, putting the patient’s health and wellbeing at risk.
Questions? 17
Thank You
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