The Gloucester Assertive Outreach Team

1
The Gloucester Assertive Outreach Team

• Presentation for NFAO
• Dr Rob Macpherson
• July 2009

2
Gloucester AO team development

• Gloucester AO team developed from community
  rehab team 2000, through change management
  process led by consultant/manager. 12 month
  training involving Sainsbury Centre with team
• -2006 major
  Trust service redesign, new team new
  management, new locality (forest of Dean)
• -move from
  caseload to team management, clearer discipline
  specialism

3
Audit/Service Development 1

• Gloucester
  Pan London (Priebe et al, 2003)
• Dartmouth score 4.3 ?
• Average age 38 37
• Unemployed 82 80
• Living alone 41 52
• Av illness duration 15 yrs 15 yrs
• Compulsory admission 23 over 1 yr 25 over 9
  mths
• Police contact 34 over 1 yr 21 over 9 mths
• Admission rate 31 over 1 yr 39 over 9 mths
• Substance misuse 29 29

4
Audit/Service Development 2

• Carers needs
• 36/75 patients on caseload have carer (NSF
  definition min 12 homes/week support).
• Staff, patients and carers rated CANSAS.
• Agreement on ratings good/excellent between
  staff and patient
• - mostly
  poor between carer and patient and between
• staff and
  patient.
• Carers rate higher unmet needs around care of
  home, lower ratings on risk to others.
• Carers assessments completed for all given up
  careers (29), independence (18)
• 
  - problems tiredness (36),
• unpredictability of patient (29)
• 
  - need someone to talk to, practical
• 
  help (finance/break/respite).

5
Audit/Service Development 3

• Changing patients needs
• From 2003 started routinely using CANSAS and EM,
  6 monthly.
• Changes-
• reduced patient rated unmet need
• no change staff rated met/unmet need
• no change in engagement measures
• accommodation changes 4 to independent living, 3
  to supported accommodation, 3 to homelessness, 2
  to prison
• 10 started Clozapine. 9 stopped depot
  antipsychotic
• 16 started regular day time activity. 0 stopped.

6
Audit/Service Development 4

• Audit Vs NICE guidelines in schizophrenia
• All keyworkers completed audit proforma for each
  of 61 cases of schizophrenia in AO team.
• Compliance with guidelines
• Formal family intervention 20 (51 no contact,
  10 declined, 15 other family work)
• CBT 40 (23 unable to participate, 18 no
  persisting symptoms)
• Advance directives 0
• Antipsychotic Polypharmacy 15 (others 5
  patient choice, 3 Clozaril augmentation, 7
  reduction of AP caused relapse).

7
Audit/service development 5

• SEAT A Service Evaluation of AO Teams
• Set up 2008, overseen by steering group
• Evaluate 1st year in AO baseline, 6 12 months
• CANSAS staff SU
• Engagement Measure
• HONOS
• Service activity admission/crisis/work/contact
  with CJS/homelessness/contacts

8
Audit/service development 6

• AO handbook
• What we do
• Simple language
• Pictures
• To be used- training induction
• -development of team
• -to address new challenges-
  CTO

9
The Gloucester AO Team structure

• Team manager band 7
• CPNs- 4 band 6
• -1 band 5
• Social workers- 2 band 6, AMPs
• OTs- 1 band 6
• - 2 band 5
• Support workers- 3
• Sports therapist- 0.5
• Team secretary- 0.8
• Psychologist band 8- 0.4
• Art therapy band 7- 0.2
• Psychiatry- 0.7 consultant (2 individuals), 1
  Associate Specialist, core advanced trainee
• Caseload 81 (70 Gloucester city)

10
Team strengths

• Journey to work team led programme of support in
  3 localities, supporting all with SMI through
  challenges of return to work
• Allotment
• Groups- walking, gym, snooker, womens group,
  badminton. Focus in normal, non-NHS settings
• Holidays- caravan, Butlins, walking

11
Team strengths

• CPA review cycle, service users seen 3 monthly
• In team training in housing, medication
  management, dual diagnosis
• 3 yearly AO half day external training
• Team supervision, daily meetings, reflective
  practice
• Red/amber/green service user assessment

12
Team strengths

• Appraisal of all team members 3 monthly
• Close working team manager/consultant/psychologist
  
• Team away days twice yearly
• Whole team caseload management 3 monthly
• Better working with recovery team, regular
  meetings with seniors 4 yearly. Transfer of cases
  greatly improved

13
Team strengths

• Flexibility working with other teams- LD,
  recovery, CRT, in-patient
• Development of specific tailor made care packages
  very effective in some cases
• Collaboration with non-stat accommodation
  providers

14
Challenges

• Rural/urban working in single team, urban
  drift. Lack of accommodation work/rehab
  opportunities in rural area.
• Consultant input to Forest arm of team.
• Interface issues recovery teams (capacity)
  crisis teams forensic cases. Ongoing work.
• Use of CTO team development, reflective practice

15
Challenges

• 2gether Trust information systems how to use for
  team development
• Requirement to input data for service evaluation
  PCT contract monitoring
• Payment by results quality improvement Vs
  managerial imperatives. Increasingly drives
  service change (activity, not outcome or
  effectiveness)

16
Future

• Raise profile of AO team locally nationally
• Applying for AO demonstration team
• Refocus project- recovery focused working
• Maintain clear AO focus, by team caseload
  management training/team support
• Closer working across teams re group other work
• RIO electronic patient record

17

• Thanks for listening