County-wide Service Research Articles

Commentary on “Specialist community teams for adults with learning disabilities: referrals to a countywide service in England”

PurposeThe purpose of this paper is to provide a commentary on the paper “Specialist community teams for adults with learning disabilities: referrals to a countywide service in England” by Isabel Clare and colleagues.Design/methodology/approachThis paper reviews some themes presented in this paper relating to the practice and management of community teams for adults with learning disability within the context of recent national service initiatives.FindingsThere is a limited literature on the practice, purpose and service caseload management of community teams. Taken in the context of recent national service initiatives, the paper by Clareet al.illustrates the gaps between the way community teams are currently processing demands and how these services will likely need to behave in future.Originality/valueThere is little recent literature examining the purpose of, and management approaches in, community teams and this addition should stimulate some further consideration of how community teams need to adjust to meet changing demands.

Specialist community teams for adults with learning disabilities: referrals to a countywide service in England

Purpose While “generic” community teams for adults with learning disabilities (CTs) are well-established in the UK, very little recent evidence is available about any aspect of their work. As part of a larger project about the role, structure and functioning of CTs, the purpose of this paper is to provide data about referrals. Design/methodology/approach Over three months, the authors obtained data about 270 consecutive new referrals to five CTs in a countywide integrated health (NHS) and care management (local authority) service. Findings The 270 referrals related to 255 individuals, mainly already service users, with almost a third (30 per cent, n=204) described as people with severe or profound disabilities. Consistent with the reported living arrangements (residential accommodation or with one or more family members (87 per cent, n=270)), referrals were most often made by social care staff, General Practitioners or carers. The referrals related to a wide range of issues including mental health and/or behavioural needs, physical health and skills, and independence. The major group, however, were requests about a person’s entitlement to specialist learning disability services and/or reviews of an existing social care package. Research limitations/implications The focus on new referrals and the exclusion of intra-team referrals mean that the data are not representative of a CT’s caseload and cannot be used as a basis for resourcing. Nevertheless, the findings emphasise the heterogeneity of the population, and the long-term and varied nature of their needs, meaning that CTs require access to a range of expertise and, often, an inter-agency approach. The implications for service design are considered. Originality/value This is the first empirical study of referrals to specialist integrated (health and care management) community learning disabilities teams in England.

A joint emergency response for those at risk of acute hospital admission in Cambridgeshire

Introduction: Cambridgeshire is a challenged health economy with a significant current overspend and consistent suboptimal performance against national targets for A&E waiting times. Community care in Cambridgeshire has undergone enormous change in the last 3 years in an attempt to address these problems. An example of this is the instigation of a county wide joint emergency team JET. Practice change: Previously there were small local schemes aimed at avoiding unnecessary admissions to acute care by providing a community response. Other parts of the county had no such provision. As part of a complete re-provision of community care following system wide consultation, a county wide service was commissioned, the JET team. This team initially comprised 6 experienced nurses or paramedics across the county who responded within four hours to a restricted number of presentations. The service has evolved to include a triage service, nursing, paramedics, therapy, care workers and access to community pharmacy. Medical input is currently provided by primary care but adding dedicated medical time is planned. Aim: The aim of JET is to prevent unnecessary hospital admission for the over 65’s or those with long term conditions by treating them rapidly and holistically at home. Targeted population and stakeholders: There are 165,000 people over the age of 65 in Cambridgeshire. We consulted widely with stakeholders including service users, primary care, commissioners, 111 service, ambulance service, acute trusts and local mental health services. Highlights: The service is in its third year. In the last nine months we received 6207 referrals. 87.9% of those have resulted in the patient being treated at home. We have engaged in repeated audits by independent GP’s to look at what is genuine admission avoidance. The latest audit suggests that 42% of patients seen by JET would have been admitted to acute care without JET. Based on the current local tariff for an acute geriatric admission the costs of admission to acute care would have been £4,431,798. The cost of the JET service over that period was less than £1,500,000. Checks ensure patients are not admitted within 30 days of being seen to be sure admission has been genuinely avoided, not delayed. Patient satisfaction is also high with 90.2% of patients willing to recommend the service to their friends/family. Sustainability: Despite some initial scepticism there is now a consensus that JET provides clinically appropriate care at home. This is popular with patients and is cheaper than admitting to acute hospitals. JET has received extra investment and will expand in size and professional heterogeneity as well as providing increased input to new areas, for example psychiatric wards for dementia and diverted calls from the ambulance service. Conclusion and lessons learned: Emergency response teams for the deteriorating frail elderly are feasible and can occur at scale. They can provide quality care in a preferred setting at lower cost. Essential to success has been whole system engagement, a willingness to adapt and change as the service developed and robust data collection to demonstrate the worth of the service.

The use of anti-psychotic and other psychotropic medication in a specialist community service for adults with learning disabilities

PurposeThe purpose of this paper is to examine the extent to which, in the five integrated community teams for adults with learning disabilities (CTLDs) in an English county-wide service, the use of psychotropic medication for service users was based on the presence of an appropriate mental health condition or epilepsy.Design/methodology/approachAdult participants were recruited following referral to one of the CTLDs for assessment, treatment and/or support of a possible mental health and/or behavioural need. Data were collected about participant characteristics and psychotropic medication 12 months after recruitment.FindingsWhile a total of 42 (78 per cent) of the 54 participants were apparently prescribed regular or PRN (as required) psychotropic medication, only 24 (57 per cent) of these individuals had a recorded past or current mental health condition or epilepsy for which such medicine could be appropriate.Research limitations/implicationsThere were several limitations: the sample size was small and its representativeness was uncertain; and data collection was compromised by barriers to explicit knowledge exchange within and across the learning disability service.Practical implicationsWhile recent guidance about the use of psychotropic medication is welcome, minimising inappropriate use requires more comprehensive person-centred interventions (including crisis management plans), underpinned by imaginative, but feasible, data collection methods and integrated formulations. Investment is needed in developments that support multi-disciplinary and inter-agency working to promote “good practice” by CTLDs in responding to referrals for possible mental health and/or behavioural needs.Originality/valueComplementing recent large studies of primary care (General Practitioner) records, this is the first examination of the use of psychotropic medication by service users in English CTLDs.

‘What vision?’: experiences of Team members in a community service for adults with intellectual disabilities

In the UK, the closure of 'long-stay' hospitals was accompanied by the development of community teams (CTs) to support people with intellectual disabilities (IDs) to live in community settings. The self-reported experiences of staff working in such teams have been neglected. Focusing on a single county-wide service, comprising five multi-disciplinary and inter-agency CTs, we measured perceptions among the health care and care management Team members of (1) their personal well-being; (2) the functioning of their team; and (3) the organisation's commitment to quality, and culture. Almost three-quarters of the questionnaires were returned (73/101; 72%). The scores of health care practitioners and care managers were very similar: (1) the MBI scores of more than half the respondents were 'of concern'; (2) similarly, almost four in ten respondents' scores on the Vision scale of the TCI were 'of concern'; (3) the perceived commitment to quality (QIIS-II Part 2) was uncertain; and (4) the organisational culture (QIIS-II, Part 1) was viewed as primarily hierarchical. The perceived absence of a vision for the service, combined with a dominant culture viewed by its members as strongly focussed on bureaucracy and process, potentially compromises the ability of these CTs to respond proactively to the needs of people with IDs. Given the changes in legislation, policy and practice that have taken place since CTs were established, it would be timely to revisit their role and purpose.

P140 Missed opportunities for ensuring adequate contraception: lessons from a rural sexual health service

<h3>Background/introduction</h3> Our county-wide service is undergoing increasing integration which makes public health sense. Ideally, risk of both sexually transmitted infections and pregnancy should be addressed with patients. <h3>Aim(s)/objectives</h3> We looked at missed opportunities for ensuring adequate contraception during routine GU appointments. <h3>Methods</h3> A retrospective notes review of 50 consecutive new female attendances over 2/12 was conducted, with a follow up at 4/12 to check contraception initiation or pregnancy. <h3>Results</h3> Consultations were conducted by 16 different staff, 44%(7) of whom are trained to initiate oral contraceptive pills (OCPs), 4 fit implants and 2 fit IUCD/IUS. 23 and 27 patients were seen by nurses and doctors respectively. Contraception methods, including none, were universally documented. 22(44%) patients were using long acting reversible methods of contraception (LARC) and 28%(14) an OCP. Pill compliance was documented in 5(36%) and advice given in 1 case. Only 4(14%) of the 28 non –LARC patients had LARC discussion. 7 patients used condoms and 7 no contraception. 5(36%) of these were advised to book a contraception clinic (CC)/GP appointment for contraception, 2 of whom failed to attend a subsequent CC. 1 patient was quick- started on an OCP. 2 patients were known to have conceived during the subsequent 4/12; 1 had LARC and 1 OCP at initial visit. 6(12%) and 1 patient/s were deemed at risk of pregnancy and appropriately provided with emergency contraception respectively. <h3>Discussion/conclusion</h3> There were missed opportunities to maximise contraception efficacy. Time restrictions and lack of staff training pose barriers which we need to address.

Ready to Read

Summary In 1997, Kalamazoo Public Library and Bronson Methodist Hospital along with several other community organizations collaborated to create an emergent literacy program. The program provides volunteer readers at community sites, pediatricians' prescription of reading aloud for healthy child development and giving books to children at well-baby visits, providing a cloth book for every child born in Kalamazoo County, offering workshops on reading and book sharing skills for parent groups and providing book collections and volunteer readers to child care centers. This program is unique in its widespread collaboration of twenty community service organizations to provide county-wide services.

Organizational conflict and mental health service system effectiveness

Conflict is a common feature of mental health delivery systems. However, there are many types of conflict and each requires specification and careful measurement. The authors present a study of mental health delivery systems in eight Oregon counties and the results of five conflict parameters that measured conflict with seriously mentally ill clients, family members, the state mental health division, county agencies, and professional/advocate agencies. Implications of the findings for countywide service systems are discussed.

Families of the seriously mentally ill and their satisfaction with services.

Family members of seriously mentally ill persons were interviewed to determine their satisfaction with services received through a countywide service system based on the community support program (CSP) model developed by the National Institute of Mental Health. Interviews with 56 family members indicated that a majority were dissatisfied with various aspects of the service system. Multiple regression analysis revealed that significant contributors to family satisfaction were sex of respondent, type of relationship to family member, age at onset of illness, and time since onset of illness. Interaction with a case manager, specifically interaction involving emotional support for families, was the strongest factor explaining family satisfaction. That finding confirms the central role of the case manager in the delivery of CSP services.

Water authority can litigate in own county

The Supreme Court of South Carolina ruled that a county water authority could not be prevented from bringing a breach of contract action against a contractor in the authority's own county. The Newberry County Water and Sewer Authority was a countywide service with 1341 residential water taps serving an estimated 4700 people out of a county population of approximately 29,000. Use of the authority's facilities was not mandatory; it sold water to customers on a contract basis. The authority brought suit against a contractor for breach of a contract for construction of a water line in the county. The contractor sought and was granted a transfer of the suit to another county on the basis that it would be impossible to empanel a jury in Newberry County that would not have a direct or indirect interest in any recovery made by the authority. The high court reversed this decision, pointing out that the limited extent of the authority's service indicated that about five sixths of the citizens of the county were not users of the authority's services. The trial court's decision, the high court said, was that the authority could not litigate in its own county. This was too drastic a conclusion, the high court said.