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Assertive outreach team (South Kirklees)
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About the service
The South Kirklees assertive outreach team works with people experiencing severe and enduring mental illness who have a history of being difficult to engage with. The person would have complex needs and would require intensive support from the service.
Service users would also have a history of psychiatric hospital admissions – on occasions, this may be under the Mental Health Act 1983 (amended 2007).
Why would someone choose the service?
- Patient choice/medication reviews
- Person-centred approach
- Patient satisfaction surveys (in progress)
- Good feedback
- Evidence that the assertive outreach team approach has reduced hospital admission for people who use the service
- The team approach in managing people who are high risk to self or others
- Quick response by the team when responding to a person in crisis
- Regular assertive outreach team visits to promote independence – including help with paying bills and medication advice
Staff you may meet
- Administrative staff provide essential support to doctors, nurses and other healthcare professionals. This can be in a variety of different settings, with administrators working as a receptionist in a clinic or a clerk on a ward. They may also be working closely with a consultant as a medical secretary.
- There are more than 60 different specialities that doctors work within the NHS. Each is unique but there are many characteristics which are common. Roles range from working in a hospital to being based in the community as a GP.
- There are many people who work behind the scenes to keep services running and you may meet them in hospital or community settings. They include porters, cleaners, plumbers, electricians, decorators receptionists and secretaries who all work to make sure healthcare settings are kept clean, tidy and safe.
- Nurses who choose to specialise in the mental health branch of nursing work with GPs, psychiatrists, psychologists, and others, to help care for patients. Increasingly, care is given in the community, with mental health nurses visiting patients and their families at home, in residential centres, in prisons or in specialist clinics or units.
- Nursing or healthcare assistants work in hospital or community settings under the guidance of a qualified healthcare professional. They help doctors, nurses and therapists give people the care and treatment they need.
- The NHS employs a wide range of clinical staff, it wouldn’t be possible to list them all on this website! All our clinical staff are skilled, dedicated professionals who adhere to high standards of training and work-place practice.
- Adult psychotherapists work with people to assess and treat a range of emotional, social or mental health issues. They help people tackle problems such as behavioural issues, common challenges such as anxiety and depression or more complex or severe issues, such as psychosis or a personality disorder diagnosis.
- Receptionists are the first link for many patients and visitors. They often work on their own or with one or two other receptionists, greeting patients as they arrive and check them in. They might also collect patient notes and ensure that these vital records go to the right healthcare professional. In a clinic, they may make appointments and arrange patient transport.
- Social workers help, support and protect people who are facing difficulties in their lives. They help people to take positive steps to overcome problems and improve their lives. This could involve assessing and reviewing a service user’s situation, building relationships with service users and their families and agreeing what practical support someone needs.
- We have a range of specialist advisors working in our Trust – they give advice on a wide range of different things, depending on what service they work in. So it could be, for example, mental health, stopping smoking, healthy eating or diabetes.
- We have a range of health workers who all have different specialities. This could be in a certain condition, a therapy or the advice they can give you. Our specialists our highly skilled and trained professionals, ready to offer you help and advice whenever you need it.
Why a professional should choose the service
- The service focuses on promoting engagement with people, identifying and managing high levels of risk.
- The service undertakes daily meetings to identify service users’ triggers of relapse and implements appropriate intervention.
- Easy and accessible access to a psychiatrist for service users and workers within the team and Trust.
- Meets and adheres to CQUIN targets
- 100% seven day follow up achieved
- Psychosocial intervention training/qualification of some professional staff
- Patient / carers satisfaction questionnaire (in progress)
- Mentoring students
- Compliments and concerns meeting to reflect on practice and implement service changes
- Multi-Agency Risk Assessment Conference (MARAC) involvement/key worker
- Safeguarding investigations
- High ratio of Community Treatment Order (CTO) patients in the team – the expertise of managing high-risk patients
- Community services
- Meets care planning CQUIN targets – physical health screening/wellbeing checks
- Good relationships and links with GPs
- Joint working with drug and alcohol services
- Three experienced allied mental health professionals (AMHP) in the team
- Good staff retention
- Regular students on placement in the team – AMHP / nursing/medics
- Monthly clinical psychology sessions/interventions
- Good links with other assertive intervention teams attending national forums
- Team expertise in working with people on a CTO, this can involve recall to hospital and revoking the CTO
Support offered
- Tenancy/housing support
- Benefits advice
- Psychological input
- Medication management
- Self-directed support process (allows people to choose how their support is provided and gives them as much control as they want of their individual budget)
- Dialectical behaviour therapy (DBT) skills – helping people to change patterns of behaviour that are unhelpful such as self-harm or substance abuse
- Referrals to other services which may be able to help further
- Social inclusion – such as football and cricket groups
- Daily living skills – cooking/ shopping/cleaning
- Group work
- Occupational therapy
- Exercises
- Education
- Family work
- Recreational activity e.g. gym activity, walking
- Self-care
- Social skills
- Health screening – physical health monitoring wellbeing clinic
- Online or virtual support
- Self-care
Outcomes
- Social inclusion
- Reduction of social stigma
- Improved quality of life
- Recovery
- Ability to self-care
- Discharged back into the community as soon as possible
- Improved engagement with community services
- Clarification of diagnosis
- Improved physical health
- Improved functional capacity (ability to carry out tasks)
- Relapse prevention
- Self-management skills
Referrals accepted from:
CMHTs, GPs, Other NHS services
Referral criteria:
Referrals to the team will need to fulfil the following criteria:
- Experiencing psychosis or bipolar affective disorder
- Receiving Care Programme Approach support (a particular way of assessing, planning and reviewing someone’s mental health care needs)
- Difficulty engaging with other services
- May have a history of repeated psychiatric hospital admissions.