AIMS

There are two key aims in the use of this model with young people with a first episode of psychosis:

i)   To engage the individual and family in a collaborative relationship which will provide a backbone for ongoing support and efforts.

ii)   To maintain continuity of contact through the critical early phase.

Key Elements

1. Human Resources

• Small caseload (client: team member ratio 10-15:1)
  
  
• Regular review of care plan for each client
  
  
• Team leader is a practitioner with a caseload
  
  
• Continuity of staffing
  
  
• Psychiatrist on staff (client: psychiatrist ratio of 100:1)
  
  
• Nurse on staff
  
  
• Substance misuse specialist on staff (client: team member with substance misuse training/experience ratio of 50:1)
  
  
• Employment rehabilitation specialist on staff (client: team member with employment rehabilitation training/experience ratio 100:1)
  
  
• Team consists of at least 10 staff.
  
  
  
  

2. Organisational Requirements

• Explicit admission criteria
  
  
• Intake rate of 6 clients per month or fewer
  
  
• Full responsibility for treatment
  
  
• Responsibility for crisis service /24 hour cover
  
  
• Responsibility for hospital admission
  
  
• Responsibility for hospital discharge planning
  
  
• Service not limited to specific time periods
  
  
  
  

3. Engagement and contact

• Team members work in the community in the clients’ own settings
  
  
• Clients do not drop out but are maintained at a satisfactory level of engagement
  
  
• Assertive engagement mechanisms including street outreach
  
  
• Service is as intense as required
  
  
• Service contacts are as frequent as required
  
  
• Services work with families and with clients’ own support system
  
  
  
  

THE MODEL

Several terms are used to describe assertive outreach, including intensive case management. For our purposes we shall consider them to be identical.

There is strong evidence which demonstrates the effectiveness of intensive community support for people with severe mental illness who have a difficulty in accessing or accepting services. This is especially the case for the services applying assertive outreach approaches where staff have low caseloads. The evidence of good outcomes from assertive outreach models is clear in at least one respect: such specialist teams can engage and maintain contact with many of even the most difficult clients. Typically, studies hove shown that at least 95% or clients are still in contact with services even after 18 months. It is for this reason that this model of sustained engagement is so relevant to people with a first episode of psychosis.

Client characteristics and needs

Many assertive outreach teams deliberately select people who have the most severe and complex problems. The typical user of such services can be described as “a single male in his early thirties who had been suffering from a schizophrenic illness for over a decade”. More than 80% of clients have at least one of the following factors; “history of self-harm, history or violence, non compliance with medication, non-co-operation with mental health services or admission within the past two years”.

However, clearly it is the client with a first episode of psychosis that defines use of this model. It may well be that during the course of early engagement, some clients may not need the sustained level of contact explicit in the model.

Operational Practice

Central to the model of assertive outreach is the relationship between the staff member and client, described by service users as the “cornerstone of care”. This requires high staff-client ratios, typically a maximum caseload of 15 clients, and sometimes 10 clients or even fewer. Staff provide considerable face-to face care when necessary, and the approach is broad and client-centred. Specific interventions or treatments are a key component of the model, but the emphasis is placed on care co-ordination and advocacy.

Usually no formal purchasing is undertaken, although this is possible if social workers or other team members are care managers and have access to social care budgets. Equally important are liaison and co-operation between the team and GPs who play an important role in providing general healthcare for the client group. Working hours of most services are flexible, although 24-hour services are rare. It is essential that some form of back up from easily accessible and well-informed staff is available.

This approach requires a multi-disciplinary team including psychiatrists, mental health nurses and social workers. Some team members have no formal professional qualifications.

These staff are of particular importance in the engagement process. The team leader plays an important role in inspiring and supervising the team, and maintaining fidelity to the purpose of the programme.

The Birmingham Early Intervention Outreach Team

The Birmingham Early Intervention Outreach Team provides intensive community support to people with a first episode of psychosis and during the first three years.

The Early Intervention Service adopts the policy of small caseloads of about 15 clients per worker, and uses “the team” assertive outreach model. The team operate a no close policy so that clients who lose contact do not need to be re-referred. Clients can also be reassured that long-term support is available. One distinctive feature of the team is the use of the “team approach”, which means that all team members work with all clients and workers do not carry sole responsibility for a client. The team is thus enabled to work evenings and weekends.