Mental Health Integrated Community Care Project

Working together to improve mental health support provided in our community

Vision for Dorset

Our vision is for people in Dorset who experience mental health difficulties to recover and have improved mental health and wellbeing with the help of personalised, localised and seamless services.

• Develop a new place based, integrated model of primary and community mental health care working as a multidisciplinary service across health and social care aligned with primary care networks.

• The new community-based offer will include access to psychological therapies; improved physical health care; employment support; personalised and trauma-informed care; medicines management; support for self-harm; support for coexisting substance use and proactive work to address racial disparities for people with SMI.

• Three key areas: Eating Disorders, Rehabilitation needs and Personality Disorder.

• Meet needs of people deemed too severe for IAPT but not severe enough for secondary care.

• Link to work to develop 18-25 transitions service from CAMHS

Key requirements from NHSE Long Term Plan and CMH Framework

• Delivery of integrated, personalised, place-based and well-coordinated care.

• New integrated primary and community MH service will be provided at a local community level

• More intensive and longer-term input for people with more complex needs will be provided at the wider community level (of around 250– 500k population).

• Increased partnership with and provision within the VSCE sector

• The ‘Care Programme Approach’ will be removed

• It is envisaged that instead of sitting in entirely separate teams, dedicated services or functions will ‘plug into’ a new core primary care model to provide rapid, evidence-based clinical input and specialist clinical expertise when needed, thus helping to maximise continuity of care.

Health

Work, education,

volunteering

Finances

Relationships, family & friends

Social life

Spirituality and growth

Home and Environment

You

Wellbeing, self management,

exercise Talking therapies

Psychiatric support and treatment

Advocacy and

navigation

Financial support & guidance

Relationship guidance

Physical healthcare

Crisis support

Education and employment

support

Cultural and spiritual healing

Wellbeing promotion and

self management

Parenting / carer support

Stable housing

Community Connections

This Photo by Unknown Author is licensed under CC BY-SA

Going on the journey together

Needs & Data Analysis

Feb – Oct 20

View Seeking

17 Aug –

9 Oct 20

Design and Modelling

Nov – Feb 21

Approvals and Assurances

Mar –April 21

Implementation & co-production

April 21 – 22

Delivery Core Service pilots

Complex Emotional Trauma & transition planning

Delivery Rehabilitation Services & Eating Disorders Services

Implementation & co-production

April 22-23

Delivery Core Service across 50% PCNs

Delivery Complex Emotional Trauma Services & CYP Transitions. Further planning priorities

Evaluations & refinements

Implementation & co-production

April 23-24

Delivery Core Service across 100% PCNs

Delivery remaining priorities

Evaluations and refinements

Intelligence, good practice gathering. Evaluations

Mental Health Integrated Community Care Project

Key aims:

View seeking

Mental Health Integrated Community Care Project

• Communication and media plan for wide promotion across Dorset

• Project Champion group to offer guidance and expertise

• 17 August to 9th October for View Seeking

• Mixed methodology with online survey, postal questionnaire and Easy Read version

• Outreach to community groups and bespoke focus groups

• Online view seeking events with community based mental health teams, Primary Care Networks and Bournemouth University

• Findings from previous relevant surveys to be included in analysis

• Independent evaluation

• Evaluation report published end of November.

Early view seeking themes from online survey

❖ Anyone who needs help with their mental health to be able to access it locally and within areasonable amount of time. Therapies should be provided for as long as necessary and shouldbe appropriate for the condition.

❖ To expand the offer of the Retreat, Community Front Rooms, REC and Connection.

❖ Partnership working and communication. Joined up services and a multi-agency approach, withclear information on how the system works and who has responsibility for what.

❖ More adapted individualised interventions offered rather than one size fits all. Ensure thatevery person with a mental health condition has a meaningful care plan.

❖ Better cooperation between services, a more coordinated system to avoid service users beingpassed around. “None of the services compliment each other- Social services, health

and GP all have different computer systems, different ways of

working and different accountability. None of the services

understand each other’s referral criteria- urgent to one is not urgent

to another.”

“There is a massive gap in services for

those with difficulties with emotions.

I think we should start reviewing use of

personality disorders as a diagnostic label

and consider use of complex trauma and

how this may be more fitting for our

clients.

I think more needs to be done to support

and provide these clients with the

therapeutic input they need as they are

often falling between the gaps of our

public services and aren't properly

supported.”

❖ Join the gap between S2W and CMH teams, between primaryand secondary care to avoid further complications and crisis.

❖ People with personality and mood disorders to be able to getaccess to evidence based therapies without long delays. Amore robust complex trauma pathway.

❖ More training opportunities would allow primary care orS2W to deal with more complex cases.

❖ Increased therapy provision within secondary care,psychologists and CMHT could also help fill those gaps.

❖ Reduction of multiple assessments. One assessment that isshared between the services with greater communicationand case study work. Easier to self-refer.

❖ Better provision for those that have a mental health condition that coexists with substance misuseof have a dual diagnosis. Availability of services for adults with eating disorders. Groups and servicesfor adults with ADHD and Autism.

❖ Better understanding and treatment for BAME and transgender groups, veterans, the homeless andolder persons with MH conditions.

❖ Improved transitions from CAMHS to Adult services

❖ Address staff shortages. More Occupational Therapists in community care. Also, more therapists, admin staff, support workers and peer support.

❖ Support to assist people with mental health conditions feel less anxious around finances. Help withaccommodation and housing, employment, training and education. Provision and informationabout local groups offering a variety of activities

‘Ultimately, the most helpful and good experiences I

have encountered is when someone took the time to

connect to me as an individual (not a diagnosis) and

listen to what I had to say, even if it was angry,

upset and confused.

Sitting with me, helped me find my own answer and

feel like I was worth living for’

Q1. What is needed to deliver this?

Q2. Who is needed?

Q3. Where is it needed?

Q4. How best could this be delivered including how should CMHT’s work change to be part of an integrated model with Primary Care?

Our vision is for people in Dorset who experience mental health difficulties to recover and have improved mental health and wellbeing with the help of personalised, localised

and seamless services.