Newport Assertive OutreachTeam

Not Just A Taxi Service

AGENDA

Introductions and Aims Songs Model of Service How Do We Make Decisions-Risks,

Rights and Responsibilities Team Approach and Statistics

SONGS

MODEL OF SERVICE

Engagement

Developing a partnershipActive Treatment

Relapse Prevention

Engagement

Shaping an effective

working alliancePsycho-social Interventions

Medication and symptom

management

ENGAGEMENTShaping an effective working alliance

Conduct outreach to establish regular contact

Being useful-provide practical help and support

Establish open, honest communication through active listening, getting to know the person behind the illness.

ENGAGEMENTPsychosocial interventions

Gaining knowledge of family Starting to assess Activities of Daily

Living Awareness of physical health Awareness/assessment of substance

misuse ‘Accepting’ conversations regarding

perceptions of mental health

ENGAGEMENT Medication/Symptom Management

Medication delivery

Ensure medication available

Monitoring medication compliance

ENGAGEMENT Medication/Symptom Management

Starting to assess side effects

Symptom acknowledgement and monitoring

Weekly medication supervision and review if necessary

DEVELOPING A PARTNERSHIP Psychosocial interventions

Continue regular contact start to negotiate continued contact

Building a trusting relationship through reliability and advocacy

Working more in collaboration towards resolution of practical tasks

DEVELOPING A PARTNERSHIP

Psychosocial interventions Information re: illness/medication if

wanted Introduction to stress/vulnerability model

through informal conversation

Informal coping strategies

Establishing relationships with family/carers as appropriate to include carers assessment, if appropriate

DEVELOPING A PARTNERSHIP

Psychosocial interventions

Identifying interests, strengths, skills and aspirations

Monitor any physical health changes.

Consider Motivational Interviewing intervention at contemplation stage re substance misuse if appropriate

DEVELOPING A PARTNERSHIP Medication/Symptom Management

Assessment of side effects

Assessment of symptoms

Reality checking

Ongoing monitoring and management of medication compliance

ACTIVE TREATMENTShaping an effective working alliance

Regular agreed contact

Supporting progress and concordance with the plan

ACTIVE TREATMENT

Psychosocial interventions

Reinforce coping strategies

Consider Occupational Therapy assessment

Consider ‘family work’ if appropriate

Physical health education and support

ACTIVE TREATMENT

Psychosocial interventions

Goal setting – strengths based/solution focused interventions-future plans-timetable for activities

Help service user to repair burnt bridges to re-establish relationships

Enlist family support for sustained lifestyle changes

Engage in MI re: Substance Misuse if appropriate

ACTIVE TREATMENT

Medication/Symptom Management

On-going support

Development of relapse indicators with service users, steps to be taken and advance directives

RELAPSE PREVENTIONShaping an effective working alliance

Maintain/consider reduction in contact

Promote development of their supportive relationships

Boost self efficiency/positive reinforcement and consider other areas of development – move towards independence

RELAPSE PREVENTION

Psychosocial interventions

Develop a formal relapse prevention plan

Continue with Psychoeduction Provide information related to health,

well being and lifestyle change Help service users learn how to obtain

information themselves Explore a service user becoming a peer

educator for others

RELAPSE PREVENTION

Medication/Symptom Management

Promote independence with medication compliance

Psychoeduction on long term use and effects of medication

Continued symptom monitoring.

DECISION MAKINGWhat interventions and when

Risks

Rights

Responsibilities

SENARIO

What risks do we need to consider

What and whose rights should be influencing our decision making?

Who holds responsibility and for what?

HUMAN RIGHTS AGENDA

Fairness Respect Equality Dignity Autonomy

HOW DO WE DELIVER OUR SERVICE

Daily handover Weekly team meeting-psychiatrist 3 monthly review of risk

management plan at team meeting 3 monthly CPA 6 month review of relapse indicators

HOW DO WE DELIVER OUR SERVICE

All staff see all service users

Different voices but the same song

HAS IT WORKED?Service user- Evaluations

Understand my problems They lift my spirit when I see them They are fascinated by my beliefs They treat me with respect I don’t feel isolated I need to be in my community, the AOT

helps with speaking to the benefit agency I haven’t got any bad things to say

except I’d like to get off the depot-they are doing their best.

ENGAGEMENT

0

10

20

30

40

50

60

Initial 6 Month 12 Month 24 Month

Average

LIFE SKILLS PROFILE

0

20

40

60

80

100

120

140

160

Initial 6 Month 12 Month 24 month

Average

MEDICATION COMPLIANCE

0

1

2

3

4

5

6

7

Initial 6 Month 12 Month 24month

Average

BED DAYS

0

2

4

6

8

10

12

14

16

18

Monthly averagepredicted bed days

Monthly averageactual bed days