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WANDSWORTH ASSERTIVE OUTREACH & RECOVERY TEAM. Dr Gunam Kanagaratnam, Associate Specialist & Dave Ramkhelawon Team Manager. BACK GROUND. Merger of two clinical management concepts Intensive care in the community Rehabilitation services in the community. Recovery Model.

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wandsworth assertive outreach recovery team

WANDSWORTH ASSERTIVE OUTREACH & RECOVERY TEAM

Dr Gunam Kanagaratnam,

Associate Specialist

&

Dave Ramkhelawon

Team Manager

back ground
BACK GROUND
  • Merger of two clinical management concepts
  • Intensive care in the community
  • Rehabilitation services in the community
recovery model
Recovery Model
  • Enable and establish remission
  • Sustain remission
  • Enable recovery
wandsworth assertive outreach recovery team1
Wandsworth Assertive Outreach & Recovery Team
  • Assertive Community Team
  • Community Rehabilitation Programme – Residential facilities in the community, Peripatetic homes – managed by the POSH Team – partial hospitalization and support at home
patient characteristics
Patient Characteristics
  • Adults with severe and ongoing mental illness
  • Problems as a result of their mental illness and needs associated with it
  • Current number of patients 143
  • In the borough of Wandsworth
referrals this is a tertiary service from the
Referrals – this is a tertiary servicefrom the
  • Community Mental Health Teams
  • Acute in patient units
  • Forensic Services
  • Rehabilitation Services
referral process
Referral Process
  • Comprehensive referral from the team to include the following:
  • Detailed psychiatric history, forensic history, risk assessment, physical health -medication history
  • History of associated substance and drug abuse
referral process ii
Referral process (ii)
  • Family history, social history
  • Accommodation / housing
  • Employment
  • Income / statutory benefits
assessment
Assessment
  • Bio – psycho – social assessment
intervention
Intervention
  • Needs lead
  • Bio – psychosocial intervention
management by the team
Management by the team
  • Multidisciplinary
  • Psychiatrist
  • Community Psychiatric Nurses
  • Social workers
  • Occupational therapists
  • Support Workers
daily meetings
Daily meetings
  • Attended by all the members of the Team
  • Hand over
  • Zoning
  • Discuss clinical and management problems

All patients in the red zone are discussed

  • Then the Clinical Case Managers proceed to visit their patients
slide13
Activities by the Clinical Case Managers –
  • Supervised medication
  • Psycho social intervention
  • Psycho education
  • Resolving their existential needs
  • Monitor mental state
  • Arrange clinical reviews
some notable achievements
Some notable achievements
  • CPA
  • Physical health monitoring
  • Clozapine treatment
  • “Direct payment”
  • Safeguarding vulnerable adults
  • Carers groups
safeguarding vulnerable adults
Safeguarding vulnerable adults
  • All persons have the right to live their lives free from violence and abuse’.
  • This right is underpinned by the duty on public agencies under the Human Rights Act (1998) to intervene proportionately to protect the rights of citizens.

These rights include

  • Article 2: ‘the Right to life’;
  • Article 3: ‘Freedom from torture’ (including humiliating and degrading treatment); and
  • Article 8: ‘Right to family life’ (one that sustains the individual).
remission criteria in schizophrenia
Remission criteria in Schizophrenia
  • The patient achieves PANSS level of mild or less

- ( score of 1 to 3)

  • On all 8 symptom items

- P1 Delusions

- P2 Conceptual disorganisation

- P3 Hallucinatory behaviour

- G9 Unusual thought content

- G5 Mannerisms and posturing

- N1 Blunted affect

- N4 Social withdrawal

- N6 Lack of spontaneity / flow of conversation

Duration of at least 6 months

definition of recovery
Definition of recovery
  • The process in which people are able to live, work, learn and participate fully in the community.
  • For some individuals recovery is the ability to live a fulfilling and productive life despite a disability.
  • For others recovery implies a reduction or complete remission of symptoms.
  • Science has shown that having hope plays an integral role in an individuals recovery.
recovery criteria
Recovery Criteria
  • Recovery criteria must be met in each of the 4 domains.
  • Improvement in each domain must be sustained concurrently for at least 2 years.
  • Level of recovery in these 4 domains is measured by symptom remission, appropriate role function, ability to perform day to day living tasks without supervision and social interaction.
notable achievements
Notable achievements -
  • Throughput of about 15%
  • Robust discharge protocol
  • Joint working with referrers
addenda
Addenda
  • CPA Form
  • Transfer of care
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