• Accept or decline forensic clients
Comments
• Requires vehicles
• If regional may require budget that deals with travel costs • Need for contractual arrangements with carers that bed is retained • May form part of an integrated service
• May require access to therapy/assessment rooms.
Option Four:
Integrated Specialist Service
Background
This approach combines inpatient treatment, assessment and management unit with specialist outreach team that is involved in both preventative and community support role eg upon discharge from unit. Residential assessment and treatment is only provided where intensive therapeutic input is required that cannot be provided within a community setting.
Patterson et al, 1995 described a US approach to the generic versus specialist debate where a collaborative system of care was developed between a community mental health centre and the mental retardation agencies in Washington state. This model is one of the few approaches that have been evaluated. The research showed that the model led to a more efficient service over a two-year period and also reduced interagency tensions.
The model specifically aimed to develop collaborative interventions and interaction between health, human services and disability services. The aim was to reduce the severity of the social ramifications of both mental health and challenging behaviour problems experienced by adults with an intellectual disability through targeted health and well-being interventions that were both social and therapeutic.
This model involves the establishment of a community-based agency that has programmes and services that are integrated with both generic mental health services and disability services. In addition to clinical outreach, education and research activities may be undertaken. Ideally there is also a relationship with other key stakeholders eg health or education. Services are locally accessible and may can be flexibly delivered eg outreach, inpatient and outpatient access.
Advantages include less reliance upon the residential model of service provision and the location of accessible resources and vices in the community. Community location ideally results in less distress and change for the client eg the person may be seen at home or at clinic. The model also relies upon the specialist services liaising with generic services therefore transferral of expertise and knowledge. Finally, generic mental health services are utilised when appropriate and possible. (Bouras et al, 1995).
This community-based, non-institutional model has been in operation within two London boroughs for more than 15 years. (Bouras et al, 1994; Bouras & Holt, 2001). This community- based service utilises generic mental health facilities including acute and medium stay in-patient beds and a variety of community resources. It should be noted that the pivot of this model is the Consultant Psychiatrists who work within this service. They are experienced clinicians who have specialist training in the Psychiatry of Learning Disability.
There is multidisciplinary team involvement in the assessment, diagnosis and treatment of adults with an intellectual disability who have high through to low support needs eg mild through to severe levels of intellectual disability (Bouras & Holt, 2001). This specialist service forms part of the generic mental health service, alongside psychogeriatrics, adolescent mental health services etc. This model adopts a lifespan approach to mental health needs. Conjoint funding is provided by learning disability and mental health services.
Evaluation of this service demonstrated that 60% of patients had a mild intellectual disability, 25% had a moderate intellectual disability and 15% had a severe intellectual disability (424 consecutive new referrals) (Bouras & Holt, 2000). 47 patients were admitted to generic psychiatric wards (11%). The majority of admissions were people with psychosis (45%) with the remainder having diagnoses of depression and personality disorder. Physical aggression appeared to be an important trigger for admission and was displayed by 50% of admitted patients (Bouras & Holt, 2000). This services has been now strengthened by the opening of a small 6 bed specialist inpatient unit in response to continued pressure for admissions for assessment and treatment of mental disorders in adults with an intellectual disability. Most existing facilities do not have the expertise or the desire, to support people with an intellectual disability when they have complex needs. Anecdotal evidence suggests that this model of care provided good outcomes for people with mild levels of intellectual disability but failed to provide well for those with more severe levels of intellectual disability (Hassiotis et al, 2000). Other criticisms focussed on the length of time spent as inpatients, suggesting that people with an intellectual disability often required longer lengths of stay that was impossible in generic mental health inpatient settings (Allen M, Bouras N, Holt, G, 1999, A Strategy for People with Learning Disabilities and Mental Health Needs and/or Challenging Behaviour; London: South London and Maudsley NHS Trust. Additionally younger people with an intellectual disability and older people with an intellectual disability may have also experience problems fitting within this model. (Hassitiotis et al, 1999).
Lead agency
• Non-government partnership eg put to tender
• Government and non-government partnership eg St Vincent’s model • DSQ alone
• Queensland Health alone eg Mental Health Unit
Clients
• Intellectual disability
• Capacity to communicate – including augmentative communication, signing etc • Age:
18 years and over 16 years and over 18 – 65 years 15-25 years Lifespan Children only
Eligibility
• Open to clients from all agencies • Lead agency/agencies clients only • Regional service
• Tertiary – whole of state
Roles
• Residential service and community outreach service that offers comprehensive assessment of challenging behaviour, development of response package and support in community settings
• Residential service and community outreach service that offers comprehensive assessment of mental health problems, development of response package and support in community settings
• Residential service and community outreach service that offers comprehensive assessment of mental health problems and or challenging behaviour, development of response package and support in community settings
• Training opportunities for clinicians – placement for psychologists, occupational therapists, social workers, medical students etc
• Training opportunities for direct care staff needing to acquire particular skills eg PART training
Entry
• Via consensus or majority of multidisciplinary clinical review – this team provides clinical and therapeutic input (unit has manager from social sciences background, not
necessarily psychiatrist)
• Via consensus or majority of multidisciplinary clinical review – this team provides clinical and therapeutic input (psychiatrist is unit manager but does not hold decision making responsibility for entry)
• Via psychiatrist
• Via unit manager who have social science background
Location
• Hospital (generic) • Hospital (psychiatric)
• Private hospital eg Belmont or Toowong • Community – suburban house/flats/duplex • Community – purpose built facility
• Jail or forensic service
Staffing Profile
• Nursing staff – RNs or psychiatric trained • RCOs or equivalent
• Rehabilitation Therapy Assistants (Wolston Park Hospital)
Length of Stay
• Short term – less than 12 weeks • Longer term – max 6 months • As negotiated
Options
• Include or exclude respite • Accept or decline forensic clients
Comments
• Problems with bed blocking
• Need for contractual arrangements with carers that bed is retained • May form part of an integrated service