Overview
A model of improving access to Occupational Therapy services whilst embedding a flexible, responsive resource for those with complex and enduring mental health needs.
Care Setting
Community care
Evidence Base for Practice
The West Fife Community Outreach Team (WFCOT) have provided intensive input to clients suffering complex severe and enduring mental health difficulties 7 days per week since its inception in 1999. The Team is staffed by a mix of generic Clinical Care Managers, with access to a small pool of generic Community Support Workers.
Since the introduction of the WFCOT, clients had no means of accessing Occupational Therapy (OT) services, other than a small percentage who were already involved in OT at point of transfer to the Team. This meant related Scottish Intercollegiate Guideline Network (guidelines 30 and 82), and the associated local OT procedures, for clients with a schizophrenia diagnosis having access to OT could not be fully met. The need for access to OT for this diagnostic group was further reflected in the proportion of those with schizophrenia who would eventually be referred to the Occupational Therapist, as opposed to other disorders covered such as bipolar illness.
This gap was highlighted in an in-depth evaluation of OT Mental Health services across Fife by the College of Occupational Therapy Advisory Service (COTAS) in 2003. Ultimately, a Senior I Occupational Therapist was seconded to set up and develop a service for clients within this Team. Funding provided a weekday service for 1 WTE on a shift pattern until June 2006. A Senior I Occupational Therapist was appointed in December 2004.
Time was given to planning and establishing the roles, boundaries, and parameters in which OT services could operate effectively, and in a way which integrated and complemented the function and roles of the established outreach team. This incorporated both professional and local practice standards, and a range of specific OT tools to enable the integration and effectiveness of the OT process.
Quality assurance/impact of practice
Whilst developing and refining the OT service within the WFCOT, several key factors were identified to adopt into practice;
Withdrawal from generic team roles to facilitate development of specialist OT roles through increased breadth and use of OT assessments, and development of the OT consultancy role
Integrate greater flexibility to work responsively as clients therapeutic needs dictates out with agreed core daytime hours
Develop and increasingly utilise existing generic support staff in carrying out OT treatment and explore dedicated hours for OT support.
Contribute actively as a generic team member focusing on staff and service development
CONCLUSION
OT to this client group is now a well established and valued resource, and is continuing to grow and evolve based on the experience and outcomes of this evaluation. The fundamental principle and most significant outcome, conceptualised by the intervention timeline in the attached document, gives recognition to the pace and scale required to begin seeing sustainable change within community psychiatric rehabilitation.
Practice Summary
Between 1999 and 2004, West Fife clients who were categorised as having complex and enduring mental health needs were supported by a generic community outreach team which followed case management and assertive outreach models of care. These clients had no access to Occupational Therapy services until 2005, and this report recounts the main outcomes of the evaluation of integrating a service to this team. Factors are highlighted which have over time firmly embedded a flexible and responsive resource within this client groups grasp, and recognises the challenges to practice which arose along the way.
Practice Detail
Boundaries were established from the outset to maintain OT as a specialist service, whilst identifying shared generic roles. This incorporated acceptance of regular duty officer role, both crisis and routine clinical telephone support, case management for a limited number of clients, and availability during crises. Generic elements of the role were in the minority, though feedback from the staff questionnaire clearly indicated support for further minimising these in order to offer a focused clinical service, simultaneously increasing the availability of the OT resource.
The Referral Priority Checklist was introduced to focus the nature of each referral, correlating themes of the services umbrella model, MOHO. The Checklist was completed via clinical discussion between the therapist and referrer, and relied upon the clinical skills and knowledge of the therapist, also fitting comfortably with the enduring nature and existing relationships between clients and their care managers. Staff feedback highlighted a beneficial consequence of the OT being integrated within the team as enhancing the referral process, as the clinician had existing awareness of clients needs pre referral.
Evidence pointed to successful and effective integration of this referral method. All OT referrals were appropriate, which highlighted specific areas of occupational functioning. All referrals led to OT goals and intervention being agreed.
Trends were highlighted from referral, specific to the diagnosis and stage of recovery, and identified by Care Managers as requiring more specialist input.
Aspects of clients habitual and volitional occupational function account for almost 75% of all positively identified referral reasons, remaining consistent with known engagement difficulties encountered by the long term, severe and enduring nature of this client group.
Challenges
Due to the complex nature of occupational goals being set, figures highlighted discrepancies. It can be inferred that the data format would require revision if considered for future use, fitting with known difficulties highlighted by Schofield (2006) in quantifying outcomes.
Despite difficulty in analysis of the specific figures from the data capture format for patient goals, a clear trend was observed relating to engagement issues and the client groups ability to sustain change over time. This also indicated required timeframes specific to the client population to observe goal achievement and, crucially, that change was sustained beyond therapy.
Additional Comments
Please refer to the attached documents for a summary report, and the full evaluation report.