Community Mental Health Team (CMHT) (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • HHSCP only
  • Primary and Secondary Care
  • Adults only

This guideline sets out the role of the Adult Community Mental Health Team (CMHT) and services and describes what they provide.

The NHS Highland North Adult Mental Health and Specialisms Secondary Care Service manage 11 Community Mental Health Services across its geography.

The Adult CMHT is a multidisciplinary team of clinicians and business support staff who enable its smooth functioning. Each Adult CMHT has a Team Leader/ Integrated Team Lead who line manages most staff regardless of professional discipline.

Each Adult CMHT will partner with a variety of non-NHS partners and agencies to help deliver its functions on a needs basis for each individual accessing the service. Each Adult CMHT should have access to a person with lived experience to assist in quality improvement of the team.

The Adult CMHT will interface with a number of other NHS Highland Based specialist services including:

  • Child and Adolescent Mental Health Services
  • Older Adult Mental Health Services
  • Drug and Alcohol Recovery Services
  • Perinatal and Infant Mental Health Service
  • Acute and Unscheduled Care Mental Health services
  • Acute and Unscheduled Care General Health Services
  • Primary Care
  • Specialist Mental Health services including Highland eating Disorder Service, Personality Disorder Service, Forensic Mental Health Service and Rehabilitation Mental Health Service

The guidelines have been produced collaboratively with Clinical, Operational and Patient/ Service user representation. The guidelines have been agreed at each stage by the Adult Mental Health and Specialisms Service Meeting and the Mental Health Clinical Governance Group.

The Adult CMHT will aim 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.

The role of the Community Mental Health Team (CMHT)

The Adult CMHT provides assessment, formulation, treatment interventions and recovery focused discharge plans for any individual referred to it

The Adult CMHT will consider Referrals from Primary, Secondary and Tertiary care of people presenting with mental disorder of significant clinical severity and complexity associated with significant risk and/or significant functional impairment. 

Most individuals referred to the team will receive a discrete episode of care in collaboration with clinician(s) who are most skilled in the treatment of the disorder with which the individual presents. Individuals will then be discharged.

A significant minority of individuals will require long-term assistance with their care and treatment from the Adult CMHT. These individuals are most likely to have an enduring mental illness. Regular review and delivery of recovery focused care will be the standard, often alongside multiple services and agencies.

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.
Guidance regarding transition from Adult to Older Adult Services is currently being redrafted. In the meantime the following previous guidance is below:
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.

Referral criteria

The Adult CMHT provides assessment, formulation, treatment interventions and recovery focused discharge plans for any individual referred to it

The Adult CMHT will consider Referrals from Primary, Secondary and Tertiary care of people presenting with mental disorder of significant clinical severity and complexity associated with significant risk and/or significant functional impairment. 

Where the criteria are met for a working diagnosis of a mental illness / disorder, as recognised by the ICD-11 (this will provide guidance regarding severity), one or more of the following should also be present: 

  • The person is no longer able to be managed solely in primary care for reasons of severity and / or complexity.

  • There is evidence of significant functional impairment associated with the mental health related presentation e.g. not being able to work, leave the house, care for dependents and meet daily self-care needs.

  • There is evidence of significant risk issues associated with a mental illness / disorder related presentation eg risk to the individual, risk to others, risk from others.

  • The referrer requires a CMHT assessment to confirm or exclude a diagnosis of mental illness / disorder where complexity has led to lack of clarity in current working diagnosis. 
  • Reasonable attempts at treatment have been made in primary care that have proved unsuccessful, e.g. if the evidence-based guidelines for depression have been followed and the threshold for secondary care input has been reached according to these
We will also provide assessment, formulation and treatment recommendations when the Adult CMHT is deemed able to provide further recovery focused care and treatment to people who have required inpatient or specialist mental health service care and treatment.

The Adult CMHT CANNOT provide:

  • Assessment for new diagnosis of Autistic Spectrum Disorder in the absence of comorbid moderate to severe mental illness / disorder.
  • Management of Acquired Brain Injury.

Referral Priority

The referrer should indicate their assessed level of priority on the referral. The following table details levels of urgency and expected time frame in which to be seen:

Level of urgency

 Expected time to be seen Clinical referral criteria
Routine Assessment offered to you within 8 weeks. Referrals meeting the general criteria for referral and where there are NO immediate concerns regarding the level of risk.
Urgent Contact to be made with you within 72 hours of receipt of referral by a clinician.

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 need for immediate admission.
Unscheduled / Emergency Contact to be made with you as soon as practicable but within same day through Unscheduled Care Pathways.

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

  • Requirement to be assessed for admission, due to immediate risk of suicide, violence or vulnerability, as a result of mental illness.
  • Psychosis evident at a level requiring admission to safely manage treatment.
  • Post-natal illness impacting on the safety of the baby.

What referral information should be provided?

Referrers are requested to provide enough clinical information to the Adult CMHT so they can efficiently triage the referral to the right professional within the MDT.

The referral criteria should be referenced to aid in the provision of information. This following list may help further:

  • Diagnosis (if known, working diagnosis is acceptable).
  • Current symptoms present.
  • Impact of symptoms on level of day to day functioning.
  • Current treatments in place or being requested of CMHT.
  • Previous treatments trialled and failed.
  • Information relating to relevant current and historical risks eg harm to self, others, vulnerability to others.
  • Relevant previous medical and psychiatric history.
  • Relevant social information.
  • Relevant past and present drug and alcohol history.
  • What questions the referrer would like answered by Adult CMHT assessment.

Risk Management

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

Referral Tips for Primary Care referrers

In addition to the list above, the following suggestions may aid in the construction of a referral:

  • Describe current symptoms reported by person and observed by referrer.
  • Describe impact of these symptoms on day to day functioning eg what is the person struggling to do or not able to do as a result.
  • What is the current working diagnosis in Primary Care? If there isn’t one what has made that difficult to achieve?
  • What treatments / Primary Care interventions have been tried to date and failed? Have treatment trials been initiated and given adequate time to take effect?

Referral management within the CHMT team

All Adult CMHT’s will follow the Adult CMHT Daily Referral Triage Standard Operating Procedure to process referrals.

Assessment, formulation and diagnosis

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.

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.

Care and treatment

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.

Discharge

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.

Liaison and communication within and with the CMHT

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.

Editorial Information

Last reviewed: 27/02/2025

Next review date: 29/02/2028

Author(s): Community Mental Health Services..

Version: 2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr AM Macaskill, Consultant Psychiatrist, Lochaber, Clinical Lead General Adult Psychiatry North NHSH, C Spratt, Service Manager, New Craigs Hospital, J Davies, Associate Lead Nurse, Raigmore Hospital.

Document Id: TAM240