VOL: 98, ISSUE: 34, PAGE NO: 40
Carlyle London, BSc, CPN, RMN, is community mental health nurse, South Kensington and Chelsea Mental Health Centre, London;Eric Craig, RMN, is operational manager/lead nurse, South Kensington and Chelsea Mental Health Centre, LondonCarlyle London, BSc, CPN, RMN, is community mental health nurse, South Kensington and Chelsea Mental Health Centre, London;Eric Craig, RMN, is operational manager/lead nurse, South Kensington and Chelsea Mental Health Centre, London
Older people with mental health problems have been found to be reluctant to use day-care facilities in winter (Brent, Kensington and Chelsea and Westminster Mental Health NHS Trust, 2001). Reasons for this include a lack of insight into their illnesses, dark mornings and evenings, concerns about travelling especially when there are poor weather conditions, fear of falling, and fear of being abused on their journey home. These people miss out on the benefits of day care and subsequently become unnecessarily unwell, requiring emergency treatment. This inevitably puts extra pressure on beds and support services at a time that is usually already highly pressurised (Department of Health, 2001).
The older people's mental health team in Pimlico and Victoria, London, made a successful bid for money to enable a small team of nurses and occupational therapists to engage this group of people in therapeutic activity and to support day-centre staff, thus helping to ease the winter pressures on health services.
A pilot scheme ran during the winter period 2000-01. Its aims were to:
- Provide assertive outreach to clients who find it difficult to engage in existing service provision;
- Use the full services of the community to promote the well-being of the older person with mental health problems;
- Offer home and group-based assessment, therapy and rehabilitation - to enable the engagement of clients with local community resources;
- Forge relationships and continue to work with local services to provide group activities;
- Develop the community team.
The team consisted of a community mental health nurse, an occupational therapist and a support worker. The CMHN and the OT did the groundwork before the start of the project and worked with the multidisciplinary team to develop an operational policy and a protocol, including a joint assessment tool, for the service. Criteria for client selection for involvement with the service were agreed (Box 1) and the pilot opened in January 2001 and ran until July that year.
The team contacted local GPs, care managers and day centres to promote the service and assess clients' needs. Questionnaires were sent to key agencies to provide a baseline for evaluating the impact of the service.
The outreach service
On referral to the team, each patient had a multidisciplinary assessment. An integral part of the service included regular visits to clients in their homes in order to continue monitoring their needs and to plan interventions. The team also developed links with other members of the multiagency team, and with voluntary and statutory agencies, to support working in partnership.
The team planned a range of activities for clients. One of the most significant aims was to support the work of the day-centre staff. Contact with staff in the centres enabled a group of clients in need of specialist input from the mental health team to be identified. Relevant information regarding the well-being of clients was shared with day-service staff and a programme of joint groups and staff training was developed.
Team members also worked with individuals in their own homes, helping with their daily lives and engaging them in therapeutic activity. An essential part of this approach was escorting people to and from the day service using public transport or by walking. It also included helping the person to settle back at home before offering further support with activities such as shopping or cooking.
Of a total of 39 clients, 45% were widowed women aged 70 to 79 (Box 2). A further analysis revealed that 27 lived alone and were socially isolated; five lived with a spouse; two lived with another family member; and five lived in a residential care setting. Half of them had had minimal contact with day-care services before referral.
Each person referred to the team was thoroughly assessed and received a diagnosis (Box 3). All clients had complicating physical illnesses concurrent with the mental health problem. These included asthma, chronic obstructive airway disease, arthritis, chronic back pain, heart disease and cerebrovascular accident. Some clients had impaired hearing, some had a visual impairment and some had difficulty with mobility.
The team's main intervention was treatment/therapy, which accounted for 80% of contacts. This included all face-to-face contact both in group format and on an individual basis. Interventions included assessment of need, specialist behavioural psychotherapy, longitudinal occupational therapy assessment and therapeutic activity in the home.
The team also met with clients and facilitated therapeutic groups. These included reminiscence, craft and discussion groups, which met at day centres on a weekly basis. Clients who needed more intensive support were seen twice a week.
Clients who used the project were given a questionnaire to assess their satisfaction with the service. Most of those who responded were satisfied with being escorted to local day services and generally felt better supported (Box 4).
During the six-month period, the team successfully engaged with 39 clients who would not normally have been involved with our service, or who would have been transferred to other services. The team was, therefore, able to provide a link between the mental health team and the day-care centres and minimise the incidence of relapse.
The team worked intensively to forge relationships with local statutory and voluntary agencies, especially with GPs and local day centres. They continued to liaise with GPs and care managers to exchange information and to ensure that clients' needs were met. Despite limited resources, the team was able to establish effective therapeutic group activities in collaboration with staff at the centres.
Clients were happy with the service, particularly having the extra support and being escorted to the centre, enabling them to maintain links with care providers during winter.
Staff in the day centres noted the benefits of having constant support and advice, as well as close links and direct contact with the outreach team, which provided quality care to a highly vulnerable client group in their own homes and in the local community.