NAVIGATING UNCHARTED WATERS

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NAVIGATING UNCHARTED WATERS
Towards a Personality Disorder Service For the
Homeless Population in Glasgow
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WHY TELL YOU ABOUT THIS?

• Although a very particular service developed in
  response to local and specific demands
• General principles may be helpful to consider
• Something to learn from cross-agency working
• Options for service design worth discussing
• Welcome ideas about evaluating service

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SETTING THE SCENE
GHN approx 80 voluntary sector homelessness
providers
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SETTING THE SCENE

• GLASGOWS HOMELESSNESS STRATEGY
• Closure of large hostels
• Diversion from hostels
• Provision of new services and accommodation
• Development of new joint assessments
• Reduction in repeat homelessness

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Improving the Standard of Accommodation

• From this..

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To this.
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Principles behind Design of Homelessness Services

• Based on health needs assessment
• Establish known gaps in service
• Identify issues around access, and consider this
  in design of service
• Work in partnership with other agencies
• Services ACCESSIBLE, FLEXIBLE, RESPONSIVE to NEED
• Re-shape services as needed

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OBJECTIVES for HOMELESSNESS SERVICES

• Improve access to services for homeless people
• Reduce inappropriate use of A/E
• Improve management and resettlement for homeless
  people with complex needs

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MENTAL HEALTH DELIVERY PLAN

• Principle of equality and social inclusion
• Better management of long-term conditions,
  including PD
• Avoid inappropriate admissions
• Extracts from commitments and targets

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HOMELESS HEALTH SERVICES
Homeless Mental Health Team Primary Care Mental
Health Team GP Practice Homeless Families
Service Physiotherapy Dieticians Podiatry Sexual
Health Service HART Homeless Addiction Team
(2007)
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Integrated Homelessness Teams (Health and
Social Work)

• Homeless Addiction Team
• 19 Health 19 Social Work Staff (nursing,
  medical, OT, psychology) 1 Joint Team Leader
• Currently supporting 629 homeless people
  with addictions.
• Research on ARBD, assertive outreach model
  used and staged engagement.
• Hostel Assessment Resettlement Team
• To carry out complex assessments on hostel
  residents to provide alternatives and associated
  care packages
• Social Work / Housing and Health Staff (OT,
  CPN, Dietician)

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Integrated Homelessness Teams

• Assessment and Diversion Team
• To assess presentations to homelessness and
  divert them away from hostel
• into appropriate support services/
  alternative accommodation
• Social work/housing, health (CPN, OT, dietician)

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New Developments in HomelessMental Health
Service Since 2004

• Discharge Resettlement Team resettle
  people from hospital
• prevent new homelessness
• reduce in-pt days
• 6 Dedicated in-patient beds
• Trauma Team
• Personality Disorder Team

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PERSONALITY DISORDER and HOMELESSNESS TEAM

• Followed from gap analysis
• Significant no. of institutionally homeless
  people difficult to house, and needs not met by
  existing services
• Many with history of complex trauma
• Many thought to have PD, although this often not
  diagnosed
• Many held by vol sector organisations

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SERVICE MODEL

• Pragmatic choice given circumstances
• Room to develop and change
• Learned from Edinburgh model
• Bateman and Tyrer (2004)
• -SOLE PRACTITIONER
• -DIVIDED FUNCTIONS
• -SPECIALIST TEAMS

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SERVICE MODEL

• Specific remit to work across all agencies in
  homeless partnership HEALTH, HOUSING, SW,
  VOLUNTARY SECTOR
• City wide
• Aim to build capacity in existing services
• 1 consultant psychiatrist in psychotherapy
• 1 adult psychotherapist/ group analyst

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MODEL COMPRISES

• Assessment and psychodynamic formulation,
  followed by consultation
• Consultation only patient not seen
• Regular complex case discussion
• Telephone advice/ liaison/ signposting
• Training
• Limited capacity for direct psychotherapy,
• Individual and group

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FIRST YEAR

• 56 Referrals,
• 31 Seen directly
• 15 Consultation only
• 6 Pending/ disappeared/ prison/ died
• 4 Redirected immediately
• Continuing effort to raise profile of team
• Significant pre-referral discussion

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SOURCE OF REFERRALS

• Statutory Organisations 39 (70)
• 22 of these from homeless services

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6
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SOURCE OF REFERRALS

• Voluntary Sector 17 (30)

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ASSESSMENTS

• 138 appointments
• Attended 67 (49)
• DNA 38 (27)
• Cancelled 28 (20)
• Not specified 5 (4 )
• Extra efforts required to track and engage
  patients
• Frequent liaison with other services

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DIAGNOSIS
Other Diagnoses Mild LD, Primary substance
misuse problem, Generalised anxiety disorder
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TYPES OF PD
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CONSULTATION

• Number 115
• Efforts made to include all involved agencies
• Model welcomed by vol sector agencies/ housing
  providers/ social work
• Health agencies prefer taking the patient
• Advantage in piggy-backing onto CPA or
  Vulnerable Adults procedures

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ROUGH SEAS

• Finding language to formulate simply
• Translating into practical advice
• Getting multiple workers/ agencies to buy into
  model
• Information sharing across agencies
• Sheer effort of constituting meetings
• Idea of own tenancy as a goal for
• all

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DIRECT TREATMENT

• Whether such a small service can provide direct
  treatment?
• Model of 1x individual 1x group
• Mentalisation based focus
• Would require good links with all those involved
  in care good case management
• Would require reasonable degree of stability

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TRAINING

• 1 Day Introduction to PD training
• Constantly under review
• Mixed groups vs tailored training to one
  organisation
• Focus on boundaries
• Attention to different learning styles
• Move from theoretical to more interactive/
  experiential

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DRAFT I.C.P. for BPD

• There needs to be a generic training programme to
  promote EMPATHY, RESPECT and implementation of
  the principles of management for all staff
• PRINCIPLES
• Establish alliance while managing risk
• Maintain flexibility
• Establish conditions to make pt safe

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DRAFT I.C.P.

• Tolerate intense anger/ aggression/ hate
• Promote reflection
• Set necessary limits
• Understand the dynamics and monitor relationship
  reducing poss. splitting
• Monitor C/Tr feelings
• Use a consistent approach

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HOW TO EVALUATE???

• Main outcomes likely to be difficult to measure
• Reduced staff stress levels
• Less staff turnover
• Better maintenance of boundaries
• Not doing harm
• Very slow change in level of chaos e.g. tenancies
  held/ less A/E presentations