Community Mental Health Team (CMHT) (Guidelines)

To provide assessment, formulation (including diagnosis) and treatment of moderate to severe mental illness / mental disorder.

To provide interventions for those with more complex and long-term needs where a variety of services and agencies are involved and also those with time-limited conditions who can benefit from specialist interventions, and who meet the guidance on referral.

The CMHT caters for people from 18 years of age to 64 years for new referrals, and for 16-17 years old if no longer at school. (This is the current situation but is subject to review).

Where patients transition, such as from Child and Adolescent Mental Health Services or between Community Mental Health Teams, liaison will take place between services to ensure appropriate transition of care.

For patients who are being re-referred to the CMHT but who have reached 65 years of age since their previous discharge, if there has been a gap of more than 2 years since discharge, the referral should be directed to older adult mental health services.

Current patients of the CMHT who reach age 65 will be maintained on caseload until their needs indicate transfer to older adult services would be appropriate. This could include onset of dementia, physical health needs that lead to frailty.

Where discreet CMHTs are in place they will consist of Mental Health Social Worker, Support Worker, Occupational Therapist, Community Psychiatric Nurse, Clinical Psychologist, Psychiatrist, Admin Staff, CMHT Leader. There may be local variation to this membership.

Where the community mental health service is located within District Integrated Teams the roles may be more generic, such as social workers not having a specific mental health focus.

The CMHT aims to work to the following general principles:

• Collaboration - working with patients, carers, family and partner organisations towards discharge from the service as safely, quickly and effectively as possible.
• Recovery - enabling patients to live a meaningful life in the presence or absence of symptoms and as defined by the individual.
• Self management - enabling individuals to successfully manage their illness / condition.
• Trauma-informed - recognising the impact of traumatic experiences on individuals, and providing appropriate response.
• Positive risk taking - involving shared decision making, personalised care, minimising variation in practice and outcomes, effective risk management within realistic expectations.

Referral to the CMHT should be considered for patients with suspected or established moderate to severe mental illness / mental disorder who for reasons of complexity, severity or lack of treatment response require specialist input (see appendix 1).

For suspected diagnosis of early onset dementia, the referral will generally be directed to the older adult mental health service.

Referrals to mental health services may include requests in relation to statutory and mandatory requirements provided by psychiatrists and specialist mental health social workers, examples include Mental Health Act work and Adult Support and Protection. There is local variation as to the route for these requests.

Referral should be made using the appropriate referral route for the locality and which can be clarified with your local CMHT. Generally this will be SCI Gateway.

The referral information suggested is:

• Demographic information, usually provided via Sci Gateway, including a telephone contact number.
• Presenting problem(s) including a description of duration and severity.
• Brief psychiatric / mental health history
• Current working diagnosis where known
• Impact on bio-psychosocial functioning
• Summary of the relevant risks (see appendix 2 for detail)
• Alcohol or substance use (legal or illegal)
• Care and treatment offered to the patient to date and response.
• Expected outcome of CMHT involvement and expectations of the patient.

Referrals will be screened daily Monday to Friday, excluding public holidays.

Patients referred / triaged as requiring an urgent response will be contacted and discussion offered regarding when an assessment can be offered. The ideal is within 5 working days of receipt though it is recognised this can vary depending on the patient’s preference and staff availability which can be dependent on factors such as the size of the team or staff absence (see appendix 4 for description of priority).

Non-urgent referrals will be assessed within 28 working days of receipt. Again, this may vary dependent on factors as in paragraph 4.2.

Crisis referrals requiring a response within 24 hours should be referred via the appropriate pathway for the locality. Details can be provided through your CMHT.

Referrals may on occasion require further information before a definitive decision can be made regarding further management. This could be due to an incomplete referral that does not include all the information as detailed in paragraph 3.4, or the referral may not indicate the presence of moderate to severe mental illness. Best practice will be to discuss the referral direct with the referrer as it is recognised that returning referrals without discussion can lead to delays in appropriate management of the referral.

CMHTs will be expected to keep a record of any referrals not directly assessed with a view to establishing any patterns that can be used to develop the service or for educational purposes.

When a referral is returned, the referrer will be written to with an explanation of the reason for the referral being returned. If this relates to incomplete information this will be detailed in the letter. If the referral does not meet criteria for moderate to severe mental illness, options for other services / signposting will be provided.

The patient will also be informed directly by the CMHT if the referral is not accepted. This will be a brief letter stating the referral has been returned to the referrer and recommending contacting the referrer to discuss the options.

Where the referrer is a locum GP (or other locum professional), the CMHT is to be aware of the potential for delays in follow up of any returned referral if the locum has moved on and in this instance it may be useful to confirm verbally with the practice that a referral has been returned and will need following up within the practice.

Standardised assessment takes place with a member of the multi-disciplinary team. On occasion two members of staff may be present for the assessment.

Aspects such as confidentiality will be discussed at this first appointment. See appendix 3.

The assessment will be discussed within the multidisciplinary team who will agree a formulation including working diagnosis and agree a care and treatment plan which will be shared with the patient. This will also be communicated to GP, referrer (if not GP) and all relevant others.

It is understood that not all GPs require a full assessment letter. However, this is the standard approach to completion of an assessment and will contribute to the patient record should the patient move area, when the detailed history and mental state will then be available. Without this, it cannot be guaranteed that a full history will follow the patient.

The assessment may identify no role for treatment from the secondary care mental health services, as following the assessment no moderate to severe mental illness is diagnosed. This will be fed back to the patient and the referrer, along with options for treatment and / or support from other services.

Treatment offered by the CMHT will be evidence based. It is recognised that there may be differences in availability of some treatment options due to variation across localities.

A care plan will be written with the patient to include the treatment and intervention being provided; the staff involved; the frequency of appointments; where possible an estimated length of treatment; the aim of the treatment.

Care plans will include risk assessment and risk management plans, identifying sources of support if in crisis and if support is needed outside of office hours.

Positive risk management will take place, with recognition that the secondary care mental health service works with patients who may present long-term high risk of completing suicide. The service will work in accordance with relevant clinical guidelines and evidence based practice.

Where required and in line with procedure, the Care Programme Approach will be used to ensure robust multi-disciplinary and / or multi-agency care planning.

The focus of treatment will relate to the mental illness, hence for patients where there are co-morbid conditions such as acquired brain injury or autism, the input is likely to be time limited to treatment of the mental illness.

Where evidence based group interventions are available for a particular illness / condition, these may be offered in the first instance. All patients referred for group interventions will meet the criteria for treatment from secondary care mental health services.

The aim is always to work towards discharge. It is recognised that there will be a proportion of patients where long term support and treatment is appropriate and which will be provided in line with ongoing clinical review and need. In line with a recovery approach there will be no assumption of a life-long intervention from the secondary care mental health service.

The CMHT will work collaboratively with patients, their relevant others and partner organisations towards a point of recovery which allows discharge as safely and effectively as possible.

Information about the treatment and support that has been provided will be communicated to the general practitioner at the point of discharge. The service is working towards a standard approach to the format of discharge information, which will include:

• Diagnosis
• Care and treatment offered and outcome.
• Anticipatory Care Plan, including supported self-management where appropriate.
• Risk assessment and risk management plans.
• Any ongoing care and treatment recommendations.
• Information regarding re-referral to the service.

A weekly CMHT meeting will take place and can include discussion of referrals; feedback of assessments; allocation of key worker; review of ongoing cases; discussion and planning of discharges; discussion of any other business relevant to the functioning of the CMHT.

Notes of decisions and outcomes from the meeting will be recorded. This will be both a discreet record of the meeting and entries within individual service user records.

Where it would be useful to discuss a potential referral, the relevant consultant psychiatrist or CMHT leader / advanced practitioner can be contacted.

Please note any referrer or general practitioner, who wishes to attend a MDT meeting or visit the CMHT, can do so by contacting the team.

The CMHT will initiate liaison with the practice/s it covers to offer aspects such as attendance at practice meetings. The level and frequency of contact will relate to agreed need and availability of staff.

Please contact the CMHT Leader or District Integrated Team Leader should you have concerns about aspects of the service the CMHT provides.

Patients should be considered for referral to secondary care mental health services when they:

• meet criteria for a working diagnosis of a moderate to severe mental illness / disorder as recognised by the ICD-10 (this will provide guidance regarding severity)

and in addition one or more of the following apply:

• they are no longer able to be managed solely in primary care for reasons of
  • severity
  • and/or complexity
• they are unable to maintain their usual level of function as a result of mental illness, examples being:
  • not being able to work
  • leave the house
  • care for dependents
  • meet daily self-care needs
• significant risk issues are identified as a result of mental illness (appendix 2)
• referrer requires a CMHT assessment to confirm or exclude a diagnosis of mental illness (of moderate to severe intensity)
• primary care interventions have been used and not been effective

There are conditions that do not fall into the remit of the CMHT but which are identified within diagnostic manuals for mental disorder. These include:

• Autistic Spectrum Disorders - at present there is no CMHT based service for the assessment and diagnosis of ASD.
• Acquired Brain Injury
• Primary diagnosis of drug or alcohol problem (the Drug and Alcohol service operates separate to General Adult Psychiatry though for some teams the referral route is the same).

The CMHT does not offer a service specifically for these conditions.

Where there is a co-morbid mental health issue requiring secondary care mental health service intervention this will be provided for that issue given the general referral criteria are met.

When identifying risks, please consider the following:

• self-harm
• suicide – ideation / intent / planning
• impulsivity / risk taking behaviour
• aggression / violence (including any specific risk towards health professionals)
• forensic history
• child concerns
• adult concerns - adult support and protection / vulnerable adult / adults with incapacity
• known risks in relation to a home visit – animals, environment
• any concerns leading to the need for 2 people to undertake the assessment
• whether on the designated patient scheme

The INSERT NAME OF TEAM / SERVICE is a team of Health and Social Care staff who work together to provide a community based care and treatment service for people who have mental health needs.  This service includes Psychiatric Nurse, Social Worker, Support Worker, Occupational Therapist, Clinical Psychologist, Psychiatrist, Administration Staff, CMHT Leader.

When you have been referred to this service any information about your illness and life situation will be treated in the strictest confidence.

Information about you may be shared, on a need to know basis, between members of the CMHT and also with your own GP.

Some of your personal details, including your name, address, date of birth and diagnosis will be entered on to our confidential computer databases.  This database is password protected and is covered by the relevant data protection legislation.

Depending on your reasons for using the service, there may be times when you need a member of staff to be in contact with other services (possible examples are Housing or the Benefits Agency) on your behalf and for this reason you may be asked to sign a mandate giving your CMHT key worker permission to share relevant information with another agency.

There are occasions when confidentiality needs to be broken with the aim of ensuring either the patient’s safety or the safety of another person. This is an unusual occurrence, but when required we will always endeavour to first discuss this with you.

If you have any queries about confidentiality, please do not hesitate to contact the person who has sent you this appointment letter or the CMHT Team Leader / District Integrated Team Leader at:-

Insert details
XXXX
XXXX
Telephone No: xxxxx xxxxxx

It is recognised that urgency of referral can be a subjective decision hence the CMHT will work with a team approach, which includes the referrer, where there are differences of opinion regarding the level of urgency.

Routine

Referrals meeting the general criteria for referral and where there are no immediate concerns regarding the level of risk

Urgent

Referrals meeting the general criteria for referral and where there are increased concerns regarding the level of risk, examples such as, but not exclusive to:

• Evidence of suicide planning but no immediate intent
• Emerging psychosis but in absence of immediate need for admission

Emergency

Referrals meeting the general criteria for referral and where there are immediate concerns regarding the level of risk including:

• requirement for assessment for admission due to immediate risk of suicide, violence or vulnerability as a result of mental illness
• psychosis evident at a level requiring admission in order to manage treatment safely
• post natal illness impacting on the safety of the baby

Personality Disorder Pathway for Crisis Admission

Below is the link to the personality disorder service information available on the NHS Highland website. This details the evidence for crisis admission and guidelines for management of the admission.

http://www.nhshighland.scot.nhs.uk/Services/Pages/Personalitydisorderservice.aspx