Oxfordshire CAMHS Assertive Outreach Service

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Oxfordshire CAMHS Assertive Outreach Service

• Kielly Alfoadari Assertive Outreach Team
  Manager
• 12 February 2009

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Introduction

• The CAMHS Assertive Outreach team evolved from an
  identification of a group of young people whose
  level of complexity needed more intensive input
  than Tier 3 services can offer and/or when
  in-patient admission was not felt to be the best
  treatment option for the young person.
• The young people for whom the service was
  developed can be split into groups (1) Young
  people with clear Axis 1 diagnosis requiring high
  intensity of treatment (2) Young people with
  complex emotional needs and emerging Borderline
  Personality Disorder traits. The service has been
  developed to meet these distinctly different
  needs with DBT treatment being at the core.
• The Assertive Outreach Service is a specialised
  element of an integrated service model of care in
  the Child Adolescent Mental Health Service
  (CAMHS) which also includes the specialised Tier
  3 teams, Child and Adolescent Forensic team
  (CAF), Youth Offending Team (YOT), inpatient and
  day services. It works closely with children,
  family young people, Education, service users
  and carers, and other key partnerships including
  voluntary organisations.

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Philosophy

• The Oxfordshire CAMHS Assertive Outreach team
  aims to support and engage children, young people
  and families with complex needs by means of
  individualised home and community treatment
  packages.
• We aim to improve and further develop the quality
  of service by enhanced working with this client
  group across all Tiers as recommended by the NSF
  standard 9 and Every Child Matters documentation.
  This will further impact and empower young people
  and families helping to improve the quality of
  services received by this identified client group
  with complex needs.

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Objectives

• To reduce out of county placements for all
  agencies
• To identify most complex young people at the
  earliest opportunity
• Deliver services in a flexible way that meets the
  individual service users needs and those of the
  family where indicated.
• Engaging with young people who have complex and
  risky behaviours
• Offer evidence based treatment for hard to reach
  young people
• To offer frequent contacts 3 per week
• To reduce frequency, length and number of
  admissions to inpatient care.
• To work collaboratively with service user and
  family in helping to sustain relationships.
• Working to improve independence and daily living
  skills of young people.

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Objectives

• Supporting young people access education,
  employment and meaningful daily activities
• Supporting families in coping and managing young
  people with mental illness/health issues
• Supporting young people and families through
  education and identification of relapse and
  crisis signature work
• Providing opportunities to increase physical as
  well as mental well being of young people.
• Care co-ordinating to ensure effective and
  evidence based delivery of care.
• Working in conjunction with multi-disciplinary
  agencies to deliver a high quality and effective
  level of care.
• Working creatively and collaboratively with
  partnership agencies to provide a high standard
  of individualised care.
• Evaluating and auditing the service looking at
  all components that encompass it.
• To aid and enhance staff recruitment and
  retention

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Access and Eligibility Criteria

• CAMHS Assertive Outreach team offer a service to
  young people between the ages of 11 to 18 years
  of age.
• Clinical/professional judgement will determine
  priority for care and treatment and will be
  focused on people with severe mental health
  problems or complex needs, associated with
  significant disability or risk, reflecting the
  requirements of the CPA policy. Assertive
  Outreach staff will advise Tier 3 Children,
  Young people and family services on the
  management of patients with less severe problems.
  Patients with primary drug and alcohol problems
  will be seen by Evolve a specialist drug
  alcohol service for young people.
• All interventions will be governed by NSF, Every
  Child Matters, NICE guidelines, and evidenced
  based practice.

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The inclusion and exclusion criteria describe the
core characteristics associated with the young
people the Oxford CAMHS Assertive Outreach aim
to engage with

• Inclusion Criteria
• 11-18 years old
• A history of frequent inpatient admissions
• Severe mental health problems
• A history of complex emotional needs and/or BPD
  traits
• Significant risk of
• Neglect (self or by others)
• Vulnerability
• Self Harm
• Abuse
• A history of dual diagnosis
• Poor history of compliance to treatment,
  medication or service engagement

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Inclusion Exclusion cont.

• A history of poor family relationship
  attachments/social support
• Intensive support needed (3 contacts per week
  minimum)
• Enhanced CPA
• Recently discharged from inpatient services A
  history of dual diagnosis
• Poor history of compliance to treatment,
  medication or service engagement
• Exclusion Criteria
• Primary Diagnosis of
• Substance misuse
• Significant learning difficulties (waiting new
  guidelines)
• No definable mental health issues
• Primary social/housing needs
• Un-containable risks/risk management in the
  community

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Team Structure

• Band 8a (1.0)
• (0.5)
• Band 6 X3 (3.0)
• Band 7 (0.5)
• Band 4 x 3 (3.0)
• Band 3 X 1 (1.0)
• Band 4 (0.80)
• Total Coast 273817

• Team manager
• Consult Psychiatrist
• Senior Mental Health Practitioners
• Clinical psychologist
• Assistant Psychologist
• Mental Health Support Worker
• Administration

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Catchment

• The Assertive Outreach service is a county wide
  service which accepts referrals from Tier 3 and
  Children young people and Family services across
  the whole of Oxfordshire. In some cases we will
  engage with young people who are out of county to
  support them in returning to the area

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Referrals

• The Assertive Outreach team works in two
  different ways a) Assertive outreach comprising
  of home and community treatment packages b) DBT
  treatment which is a specific intervention for
  young people with BPD traits.
• Referrals will be accepted by Oxfordshire CAMHS
  Assertive Outreach Team from the following
  sources
• OBMH CAMHS Acute inpatient services in discussion
  with care-coordinator
• Oxfordshire based CAMHS Tier 3 services
• CYPF Looked After and Leaving care services
• CYPP Attach team
• OBMH CAF team
• EDB schools

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Work Streams
Assertive Outreach Work Streams
EDB Schools
Dialectal Behaviour Therapy (DBT)
Assertive Outreach (Axis 1 diagnosis)
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• Referrals will be classified as
• Assertive Outreach all initial assessments
  should be offered within 7 working days or
  sooner.
• DBT- will be offered an initial assessment within
  3 weeks of receiving the referral
• Crisis interventions would be considered on an
  individual basis.
• School Referral.

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Caseload

• It is envisaged to move towards an indicative
  maximum team caseload to ensure adequate care and
  team review when
• Each full time Care Co-ordinator should have a
  maximum of 15 patients on their caseload.
• The team will hold a maximum of 40 cases
• Team and individual caseloads will be regularly
  monitored and reviewed in management supervision.
  The Consultant Psychiatrist, Team Manager will
  maintain an overview to ensure Assertive Outreach
  DBT members are able to provide immediate
  effective care for new referrals or to increase
  contact during crisis.
• Ten additional cases from two special schools
  will be also held by the team

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Care pathways Axis I disorders
Referral Tier 3
Tier 4 or 3.5
Inappropriate referral
Assessment
Care coordinator assigned and CPA process
Engagement process Build therapeutic
relationship
Plan and deliver intervention
CPA
Discharge
Intervention to continue
Tier 3
Sign Post
In-patient
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Complex Emotional needs
Referral Tier 3
Referral modern matron
Referral Inpatient
Assess
Care Coordinator assigned and CPA Process
Identify need for Outreach or DBT or Both
Appropriate for DBT Outreach
Not suitable for DBT
Appropriate for DBT only
Engagement
Pre-Treatment
Refer to Outreach
Pre-treatment DBT
Group and individual Work
Outreach Pathway
Group Individual Work
Discharge from Service
Discharge back to inpatient
Signpost
Discharge back to Tier 3
or
or
or