Primary Care

1
In Partnership With

• Primary Care
• Mental Health Services

2
Key Partnership Strengths

• People and process in place
• Existing infrastructure relationships
• Clinical supervision
• Governance
• User / Carer Involvement
• Social Inclusion
• Far more than a clinical service
• Partnership geared to patient flow across
  primary, secondary and social care
• Unique opportunity to co-ordinate mental
  healthcare pathways
• The comprehensive service components range from
  prevention and promotion through to specialist
  care.
• Unique opportunity to co-ordinate mental health
  services

3
Key Partnership Strengths

• We understand our community
• We are an integral part of this community
• Diverse communities
• Social economic drivers
• Neighbourhood co-ordination areas
• Were already improving our community through LSP
  LAAs.
• We are already thinking to the future
• Potential service development opportunities
• Capacity building with Third Sector involvement
• Social Enterprise
• Expanding social care involvement
• Workforce modernisation.
• Open to Ideas Innovation

4
Partnership Board
The Partnership Board will relate to the PBC
Board / Commissioning Group and will also have a
direct link to the Mental Health Leadership
Network.
5
Access Referral Model

• Key Elements for a Single Point of Access
• Virtual
• Referral into Service by practice based or
  central hub based Personal Advisor
• Personal Advisors Band 6 trained mental health
  case managers who will triage and discuss with
  service users / carers appropriate treatment
  options.

Job Centre Plus / Conditions Management
Practice Nurses
Housing Association
Duty Personal Advisor based at the Hub (i.e.
Daisyfield)
Practice Based Personal Advisor
General Practitioners
Probation Service
Mosques Community Groups
Allied Health Professionals
Self Referral
Single Point of Access Delivers Highly Effective
Triage
6
Step 1 Promotion, Prevention and Recognition
7
Step 2 Mild to Moderate Common Mental Health
Problems



Triage (Paper/Phone
based brief triage)
Referral to PCMH Service
Offer of face-to-face detailed assessment with a
Personal Advisor.
Go to Condition Management Programme
Go to supported employment service
Back to Step 1
cCBT offered at a range of community venues
facilitated by a B3 STR Worker
Allocated to Graduate Worker (B5) for guided self
help (Note first session face-to-face, further
sessions mainly by telephone)
Go to Step 3
Go to allocation Meeting Step 3/4

6-12 week process
6-12 week process
Social support provided by trained and supervised
volunteers.
Allocated to B5 Graduate Worker for Supervised
brief 11 intervention
Brief Counselling B6 Counsellor
Allocated to B5 Graduate Worker for supervised
brief group intervention
6-12 week process
6-12 week process
6-12 week process
Evaluation
Back to triage with Personal Advisor and
assessment/stepped up to Step 3
Little or no significant improvement
Significant Improvement no further services
needed
Discharge with relapse plan
8
Step 3 Moderate to Chronic Mental Health Problems
9
Contingency Arrangements

• Datix Web ensures a live flow of information in
  order that issues/risks are highlighted and
  contingency plans can be implemented in a timely
  manner (i.e. standard business intelligence
  tool)
• Continual review of how resource is being
  utilised (for example in South Tyneside where the
  Stepped Model is in operation this reviewing of
  resource utilisation created a shift to more
  telephone counselling). This is a fluid service
  that adapts to internal and external
  requirements)
• Appropriate staffing mechanisms (e.g. deputies
  and succession planning)
• Up-skilling of staff
• Support from appropriate healthcare professionals
  (e.g. CMs, HVs)
• Organisational contingency underpinned by Major
  Incident Plan.
• Live Information and Strategic Planning Strong
  Timely Contingency

10
Clinical Supervision Arrangements

• The size of LCT as a partner organisation allows
  flexibility in terms of supervision (i.e. large
  pool of local resource)
• Supervision of Advanced Practitioners (by minimum
  8a Practitioner)
• Clinical supervision undertaken by Case Managers
• A range of approaches to supervision in order to
  maximise controls (11 and group)
• Robust supervision arrangements will ensure
  safety and ethical framework for staff.
• Clinical Supervision is Mandatory, Audited
  Evidenced

11
Clinical Outcomes

• The model presented is comprehensive and designed
  to deliver the chance of the best possible
  outcome
• The model presented has been designed to respond
  to a range of mental illnesses
• The model presented has taken onboard evidence
  from CSIP pilot studies
• CORE-OM has been utilised within many of the CSIP
  pilot sites. Core-10 and will be used within the
  service
• PHQ9 and HADS are currently used with the mental
  health services that BwD Teaching PCT currently
  deliver and would continue to be used (these
  could form part of the referral process).
• We Strive for the Best Possible Clinical
  Outcomes for Service Users

12
Clinical Outcomes continued.

• Within the higher steps appropriate standardised
  tools would be used (including CORE-OM)
• To ensure integrity and quality of data an
  outcomes and performance framework will be
  implemented (based on IAPT Outcome Framework)
• In summary the following tools will be utilised
  to monitor clinical effectiveness PHQ9 HADS
  GAD7 CORE-10 CORE-OM
• The IAPT Patient Experience Questionnaire Part 1
  (PEQ1) will be administered to service users
• It is important to note that the service will
  also collect a range of none clinical data for
  example relating to inclusion and Employment
  Status.
• We Strive to Improve Wellbeing Life Chances
  for Service Users

13
Audit Governance
Due Diligence In Everything We Do
14
Thank you

• Questions?