Overview
The development of a safer, more efficient and timely system for the assessment of new referrals to a community mental health service.
Local Area
Dumfries and Galloway
Care Setting
Community care
Evidence Base for Practice
Much time was spent as a team discussing how the model should look. We wanted to provide a multidisciplinary assessment that improved the experience of the patient by making treatment planning and diagnosis quicker. We calculated the number of assessments and reviews that took place from the previous year. Offices and meeting rooms were booked 12 months in advance and all staff committed their time and energy to make this model work. Roles and responsibilities were redefined and agreed. With support from our Clinical Governance colleagues, we identified the quality measures required to demonstrate whether the new model was effective.
We had previously used assessment tools and outcome measures and were committed to ongoing training with these. We hoped this new model would also provide a safer way of working for us and for future student and new staff placements.
We planned to build upon the existing Integrated Care Pathway Process (ICPs). This process provides a structure for the coordination of a single point referral system; weekly allocation meetings; assessment; care planning and review. We identified the need to fit within the strategic aims of our organisation and worked closely with the Mental Health Development Manager.
Quality assurance/impact of practice
The new model for assessment has been a resounding success. Satisfaction questionnaires demonstrate a positive response from patients. Patients are being seen more quickly. Our initial worry about asking patients to travel to the assessment clinic was not borne out and indeed many of the respondents preferred the anonymity that the Primary Care Centre (PCC) provided.
Time is being used much more efficiently and there is definitely a reduction in the duplication of work. Assessments are being completed consistently and confidence in assessing different conditions is improved. The assessment process feels safe and supportive for all staff involved.
The improvement in our review processes has been significant. Booking patients in for reviews is straightforward and painless. This reviewing system has cut down on repetition and created more time for staff, which is a considerable bonus.
We have developed and demonstrated efficient processes that are robust enough to cope with unexpected staff absences and protects vital time for staff.
Practice Summary
In December 2006 the Stewartry Adult CMHT moved into a brand new Primary Care Centre. This provided a unique opportunity for us to use offices, consultation rooms and have easy access to other health and social care teams that were all based in the same premises.
The development of a safer, more efficient and timely system for the assessment of new referrals to the team was identified by the CMHT as an area for service improvement. Prior to the development, we had identified a clear contributory factor in the hold up of diagnosis and treatment of individuals. This was the time delay between initial assessment by the key worker and a second appointment being coordinated with the key worker and medical staff.
We also identified duplication of work, both within the assessment process and the reviewing of existing cases. Prior to our development, reviews would be held either at the Psychiatric Outpatient clinics or by coordinating meetings. This arrangement could be rather cumbersome and time consuming as it meant coordinating many diaries and then finding the available room to meet which delayed review meetings considerably.
We were also concerned that the increasing demand of workload on all the staff was not balanced by any increase in resources and that we needed to streamline our service to take account of this. We planned to make better use of our time and our new accommodation and hoped to deliver a more efficient, safer assessment and review process.
Practice Detail
At the referral meeting the needs/possible diagnosis of the patient are discussed taking into account the referral information provided. Any pre-assessment tools felt to be of value are sent out to the patient prior to the appointment eg EAT or BITE in the case of suspected eating disorder. On the day of the assessment clinic a member of the multidisciplinary team (OT, CPN, MHO) meets with the patient first, taking previous history and completing a mental state examination. They may for example carry out an ACE-R with the patient if there are perceived cognitive difficulties. This process can take in excess of 45 minutes. The assessment worker then discusses their findings with the consultant and/or the rest of the team.
The consultant and the worker then jointly see the patient for the next part of the assessment process. The consultant speaks with the patient, clarifying any points he needs to, to fulfil diagnostic criteria. If possible the patient is then given a working diagnosis and treatment options discussed with them. Information leaflets regarding mental illness, medication and any useful self-help guides etc can be made available to the patient at this time. The majority of patients leave the clinic with a diagnosis and a treatment plan, including follow up details. The completed assessment is discussed at the allocations meeting prior to this decision being taken.
Following the clinic the consultant writes to the GP and also the patient reinforcing what has been discussed and enclosing any additional information which may be necessary. This correspondence takes place even if further assessment meetings are required. When a further assessment or subsequent appointments are necessary this will be explained to the patient at the end of the assessment. The person completing the first assessment will not necessarily be key worker in the case. The completed assessment is discussed at the allocations meeting prior to this decision being take
Challenges
In addition to the new model for initial assessments we wanted to plan reviews of existing cases in a more coordinated, participative way. Similar to the assessment clinic, we identified the number of reviews required over a 12-month period. We created a booking system for these reviews and key workers used this to plan ahead. This has helped coordinate reviews in a multidisciplinary way and reduce individual staff replicating work.
The introduction of the AVON outcome measure has encouraged user participation in their review.
Additional Comments
One of the team’s positive qualities is the way in which all members support each other and respect each other’s expertise and opinion. Notwithstanding this, we all felt rather vulnerable, prior to the new system, when presenting recommendations to medical staff from assessments and the expectation from medical staff to recommend treatment for people they had not seen. Team members were anxious about such an arrangement .
We also wanted to improve our communication with patients post diagnosis by writing to them after the assessment. This correspondence explains the reasons the diagnosis was made and details any recommendations and follow up arrangements and gives the patient a written summary to refer back to.