Developing tools to help in serious mental illness

Mental Health Nursing,  May 1999  by Young, Norman,  Hopkins, Andrew,  French, Gill

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As community mental health teams seek to redirect their resources towards those with severe and enduring mental illness, community practitioners need the skills and tools to work effectively with such clients. NORMAN YOUNG, ANDREW HOPKINS and GILL FRENCH describe how their CMHT developed tools for assessing need and addressing social and health gain for clients in their care.

Mental Health Nursing 1999; 19, 3: 9-12

One of the challenges in raising the quality and effectiveness of care for those with serious mental illness is to develop an organisation's structure and culture to enable and encourage the practise of clin-- ically effective skills pertinent to this client group.

This article reports on the South Rhymney Valley CMHT, and one part of the organisation's change strategy. The team came from a position of working with people with problems predominately of depression and anxiety. In order to bring practitioners closer to those with severe and enduring mental health problems, a strategy was implemented in order to develop a model of practice that met national aims and Welsh Office strategic intent.'23

The strategy had four parts:

* reorienting the team's culture through teambuilding and education

* maintaining this change by developing tools (workbooks, assessments and educational material) that would structure and stimulate work with this client group

aiming to train one person to an advanced level in psychosocial skills and disseminate these through the team

reducing the demand on services by developing liaison and training links with primary health care professionals.

The second part of the strategy - developing and evaluating tools, within the constraints of clinical practice - is presented here.

Health gain

In encouraging purposeful work with those with severe and enduring mental health problems, the team appreciated that practitioners needed to work within a clinical framework with clear goals. A working party began designing tools that would rest easily within clinical audit and address social and health gain targets published by the Welsh Office?

In order to limit the project, and therefore make it more manageable, the social and health gain targets were reduced to four areas:

* needs assessment

* prevention of relapse and suicide prevention of physical morbidity and mortality

* increasing social functioning.

Following a review of the literature, a series of As booklets was written to address each target. The booklets, or 'check packs', were designed so that information could be worked through and details recorded by clients, carers and the keyworker. The booklet was retained by the client and reviewed according to the service standard, and care plan. The design of, and rationale behind, each booklet is discussed below.

Needs assessment

A needs-assessment tool enables the creation of the care plan and is a means of reviewing progress. Although there are many needs assessments available,4 they did not meet entirely the requirements of the team, as many are constructed for research and lack the ability to facilitate care-planning during their application.

The working group created a needs assessment based on the Reed and Sanderson model of adaptation.5 A series of zo questions was written that represented each part of the model. These were then incorporated into a booklet called the Quality of Life Assessment.

This is a collaborative tool engaging the client, carer and keyworker by provoking the discussion of need, measuring satisfaction, and beginning the process of care planning through the identification of needs, desired outcomes and action.

Each question has a devoted page with three parts. Part A asks the client to describe an aspect of his or her life. Below the question, two situations are described outlining the extremes of possible answers. Separating them is a horizontal line representing varying levels of functioning. The answer can then be scored one to five.

Part B asks the client to rate his or her satisfaction with the issue raised in Part A. For example: 'How satisfied are you with your housing situation?' After asking the question the client is referred to the back page of the booklet, which shows a series of faces, from smiling to unhappy. The client points to the face that accurately represents his or her level of satisfaction and this is recorded on a one-to-seven point scale.

Part C provides a blank boxed area in which to identify needs, define desired outcomes and agreed action. In this way the booklet moves away from emphasising the translation of need into numerical data, and serves as the client's care plan. On the last pages overall satisfaction with life is measured using the faces and space given to prioritise needs and action.

Prevention of relapse and suicide

Interventions that address the high risk of relapse in serious mental illness were a priority for the team. Between 4o per cent and 6o per cent of those with a psychotic illness relapse within the first two years of treatment, and when patients are abruptly withdrawn from anti-psychotic medication, 50 per cent will relapse within six months.6 The consequences of relapse can be grave, with an increase in the frequency of relapse and declining social and cognitive functioning.