Care Cluster 17: Psychosis and affective disorder(difficult to engage)

Description: This group of patients has a history of psychotic symptoms and affective symptoms. The symptom severity will vary from severe to very severe especially lack of insight into the mental illness. Symptoms might not be controlled or may even be treatment resistant and patients can be difficult to engage and treat. This has a major impact on role functioning, social relationships, occupational potential and family.

Review period: 6 monthly and will require more frequent review compared to other clusters including more frequent medical review

Cluster Duration: 3 years plus (review every 6 months).

Duration: Long Term

Aim of Intervention: Prevent or delay relapse, maximise role functioning, reduce risk to self or others and promote better adjustment to situation with a view to return patient to previous level of social role functioning and achieving a significant improvement in quality of life. Treatment for clients with high levels of risk to self and others and poor engagement.

Assessment: Comprehensive MDT assessment of Health and Social Care needs-including physical, social and mental health risk assessment with due care given to safeguarding and vulnerability issues (CPA assessment tool) Assessment to identify current coping strategies for managing distress and dealing with difficulties and to understand the emotional impact of symptoms and individual experiences.Assessment process may last up to 6 weeks, and a handover CPA meeting has to be arranged between both teams (good practice dictates this should not exceed 4 weeks following formal acceptance by a service)

(This template should be read in conjunction with latest Mental Health Clustering booklet Version 3.0 2013/14)

Function / Resource / Time / Frequency / Outcome
1: Treatment Planning / Core Interventions
  • Ensure assessment complete
  • Assess level of engagement
  • Allocate care co-ordinator
  • Review risk- identify coping strategies and strengths for managing distress and dealing with difficulties
  • Bio-psycho-social formulation
  • Check for co-morbidity including substance misuse and/or personality disorder
  • Diagnosis or formulation
  • MDT discussions and joint assessments
  • Medication review / Metabolic monitoring
  • Choice of treatments, plan, review predict and evaluate
  • Safeguarding
  • Assessment of carer / family (including dependents) needs and signpost where appropriate
  • Social/housing/benefits support
  • Legal support if under MHA
  • Clarify goals for patient
  • Assess need for acute inpatient care pathway
/ (Delivered by appropriate professional/ professionals)
Other disciplines may be involved according to clinical presentation e.g.
  • Care Coordinator
  • Psychiatrist
  • Nurse
  • Clinical psychologist
  • STAR worker
  • OT
  • Social Worker
  • Trainee/student with supervision
Other professional or agency / 1 – 2 hours / 2 - 3 sessions
(recorded via MDT and face to face meetings) / All patients will be on CPA
Provided patient information leaflet on diagnosis
Provided with care plan with clear goals
Morgan Risk Assessment completed
Carers assessment where appropriate
Patients offered choice of:-
  • Medication (different types) (Provide information leaflet on medication/ Ward information booklet, where appropriate)
  • Psychological interventions (where appropriate)
Offered copying correspondence where appropriate
Compliance with NICE
Core Interventions
2: Delivery /
  • Care plan in line with CPA, and care coordination
  • Identify goals
  • On-going evaluation of treatment plan
  • Medical care- medication choice/ review/metabolic monitoring
  • Physical health and well-being interventions
  • Psychological and social interventions are identified by assessment, including psycho education.
  • Social care- benefits/housing/educational/vocational/occupational needs to be addressed
  • Liaise with team members for review as appropriate including social services to ensure assessment of accommodation needs
  • On-going assessments – risk/capacity/safeguarding etc.
  • MDT discussions and team reviews
  • Professionals meetings as needed
  • Team working and supervision for staff
  • Relapse prevention and develop crisis and contingency plans
/ (Delivered by appropriate professional/ professionals)
Other disciplines may be involved according to clinical presentation e.g.
  • Care Coordinator
  • Psychiatrist
  • Nurse
  • Clinical psychologist
  • STAR worker
  • OT
  • Social Worker
  • Trainee/student with supervision
Other professional or agency / 1-2 hours per week / 1 – 2 sessions per
week / All patients will be on CPA
Provide updated care plan
Compliance with NICE guidance
6 Monthly:-
  • HoNOS and cluster review
  • Service user experience questionnaire
  • Carer experience Questionnaire (if appropriate)
Compliance with NICE
Review patients under MHA as per clinical need and legal requirements
Joint working with other providers
Supplementary Interventions
  • Referral to SpA and In- patient treatment where appropriate
  • Physical health checks and health promotion/annual health and other screening checks
  • Support and facilitating engagement and attendance for appointments for physical health/ other services
  • Psychological care- PSI interventions, direct and indirect psychological input including psychological therapies; motivational interviewing
  • Addressing concerns with regards to environment
  • ADL/OT assessments
  • Personalised budgets as needed
  • Substance misuse advice( dependant on severity/harm)/ Referral to dual diagnosis team ; drug and alcohol services as appropriate
  • Family intervention
  • Religious/cultural/spiritual needs as needed
  • Neuropsychological and cognitive assessments as required
  • Assessment of carer / family (including dependents) needs and signpost where appropriate
  • Referral to other mental health services as needed (e.g. forensic
/ As required / Admission to hospital
Core Interventions
3: Review (in line with CPA policy) /
  • Review patients’ strengths, achievements and goals in line with recovery model
  • Biopsychosocial review
  • Cluster review
  • Risk review
  • Employment/Accommodation
  • Contingency planning
  • Carer review
  • 3rd Sector on-going support
  • Residential care and support
  • Specialist placement
  • DOLS , advance decisions
/ (Delivered by appropriate professional/ professionals)
Other disciplines may be involved according to clinical presentation e.g.
  • Care Coordinator
  • Psychiatrist
  • Nurse
  • Clinical psychologist
  • STAR worker
  • OT
  • Social Worker
  • Trainee/student with supervision
Other agency or professional / 1-2 hours/ meeting / 6 monthly or earlier as required / Completed cluster review
Updated care plan and risk assessment
Satisfaction questionnaire
Sharing of care plan with service user/carers
HONOS at each review
Symptom rating scales
Review patients under MHA as per clinical need and legal requirements
4: Next steps /
  • Transfer to different cluster pathway provider- including advance planning/joint working as needed
  • Manage ending and transition
  • Signposting for extended support
Re engagement discussed
  • Sign posting for on-going carer support
/ (Delivered by appropriate professional/ professionals)
Care Coordinator
Psychiatrist
Nurse
Non- medical prescriber
Clinical psychologist
STAR worker
OT
Social Worker
Trainee/student with supervision
Other agency or professional as needed / As per clinical need / As per clinical need / Satisfaction and feedback questionnaire
Handover CPA

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