Wandsworth assertive outreach recovery team
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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


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

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



  • Bio – psycho – social assessment



  • 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

Wandsworth assertive outreach recovery team

  • 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



  • CPA Form

  • Transfer of care

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