NAVIGATING UNCHARTED WATERS

2. 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

3. SETTING THE SCENE Ghn � started life as glasgow council for single homeless � is a membership org for vol sector homeless providers.Ghn � started life as glasgow council for single homeless � is a membership org for vol sector homeless providers.

4. SETTING THE SCENE GLASGOW�S HOMELESSNESS STRATEGY Closure of large hostels Diversion from hostels Provision of new services and accommodation Development of new joint assessments Reduction in repeat homelessness

5. Improving the Standard of Accommodation From this�..

6. To this.

7. 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

8. 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

9. 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 These are taken from the commitments and targets in the Scottish Exec�s mental health delivery planThese are taken from the commitments and targets in the Scottish Exec�s mental health delivery plan

10. Giving you this information to illustrate the extent of homelessness services, and how they have developed from a single dedicated CPN in the early 90s, to a complex system of services. Start here with the primarily health based servicesGiving you this information to illustrate the extent of homelessness services, and how they have developed from a single dedicated CPN in the early 90s, to a complex system of services. Start here with the primarily health based services

11. 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) Then on to integrated teams, established ahead of mainstream Comm Health Partnerships Then on to integrated teams, established ahead of mainstream Comm Health Partnerships

12. 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)

13. 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

14. 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

15. 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 EDINBURGH experience: Audit of PD prevalence in homeless population � Rough Sleeper�s funding, Followed by 1 year COWGATE project, joint funded by health and housing � assessment and consultation, looking at effects on sustainability of housing, Then current service � 1 clinical psychologist providing assessment/ consultation/ brief intervention/ training SOLE PRACTITIONER: well-meaning individual; can benefit some mild disorders, but can impede recovery in more complex cases DIVIDED FUNCTION: specialist therapists providing interventions, while community team manages case SPECIALIST TEAM: more holistic team-based approach (involving other agencies e.g. probation, housing, social care) Includes management of the case for continuityEDINBURGH experience: Audit of PD prevalence in homeless population � Rough Sleeper�s funding, Followed by 1 year COWGATE project, joint funded by health and housing � assessment and consultation, looking at effects on sustainability of housing, Then current service � 1 clinical psychologist providing assessment/ consultation/ brief intervention/ training SOLE PRACTITIONER: well-meaning individual; can benefit some mild disorders, but can impede recovery in more complex cases DIVIDED FUNCTION: specialist therapists providing interventions, while community team manages case SPECIALIST TEAM: more holistic team-based approach (involving other agencies e.g. probation, housing, social care) Includes management of the case for continuity

16. 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

17. 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

18. 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

19. SOURCE OF REFERRALS Statutory Organisations � 39 (70%) 22 of these from homeless services

20. SOURCE OF REFERRALS Voluntary Sector � 17 (30%) Surprised by this low figure. Are often involved in the case, and attend meetings more readily, and feel supported by this � have a higher degree of PRESENCE in our ongoing work. Also sometimes referrals made by mental health service workers in order to elicit our support/ input to team such as supported accommodation staff group/ to support a tenancy.Surprised by this low figure. Are often involved in the case, and attend meetings more readily, and feel supported by this � have a higher degree of PRESENCE in our ongoing work. Also sometimes referrals made by mental health service workers in order to elicit our support/ input to team such as supported accommodation staff group/ to support a tenancy.

21. 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 Don�t have details of WHERE seen � all over city � ongoing struggle to identify rooms. Maintaining core of psychodynamic assessment out of a usual clinic setting. Importance of our consistency in offering the time and place � difficulty that people with no experience of consistency have in taking this up. We have put aside 50 mins � can use however much of this you want/ able to. Don�t have details of WHERE seen � all over city � ongoing struggle to identify rooms. Maintaining core of psychodynamic assessment out of a usual clinic setting. Importance of our consistency in offering the time and place � difficulty that people with no experience of consistency have in taking this up. We have put aside 50 mins � can use however much of this you want/ able to.

22. DIAGNOSIS Out of the 31 seen directly, plus few others with established diagnosis. Set out to use IPDE � only managed in 4 cases!!!Out of the 31 seen directly, plus few others with established diagnosis. Set out to use IPDE � only managed in 4 cases!!!

23. TYPES OF PD

24. 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

25. 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

26. 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

27. 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

29. 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

30. 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

31. 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