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Guideline Two
A key worker should be allocated early following referral of the case in order to develop engagement and rapport and to 'stay with' the client and family/friends through the first 3 years (the 'critical period') preferably within an assertive outreach model.
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Background
A positive trusting relationship between the worker, client and their family/friends is the bedrock on which recovery is based. This is particularly important at the time of first contact with services where the client's and families' impressions of services are formed. The process of engagement should be viewed separately from the offer of treatment.
The development and implementation of a programme of intervention requires ongoing effort and continuity of contact with the case manager. Early identification of relapse, adherence to treatment regimes and the promotion of psychosocial recovery all require consistent and steady input throughout the critical period.
Requirements
- A case manager needs to be allocated to each client with a first episode on referral and following assessment to 'stay with' him/her for 3 years, preferably within on assertive outreach framework. Continuing support needs should be reviewed at this stage.
- Engagement and relationship building is a therapeutic goal itself and should always involve the client's family and social network.
Getting it right....
Christopher was seen at the GP surgery by a CPN after the GP was concerned about the onset of a mental illness. Whilst Chris was reluctant to see a psychiatrist, and failed to attend on appointment, the CPN was able to contact and arrange supervision between psychiatrist and GP to organise neuroleptic prescribing. The CPN maintained regular contact with Chris in person or by phone. Liaison with family members was also continued even at times when Chris declined contact. The keyworker arrangement provided a link and clear pathway should Chris deteriorate.
Where things can go wrong....
Steven was referred for assessment by his probation officer who was concerned about his deteriorating mental health and grasp on reality. At times, he presented well but on closer examination, had persecutory beliefs and issued death threats. He was admitted to hospital for assessment prior to a court appearance by the on-call psychiatrist. During his 5 day stay on the word, he did not display any overt psychosis. He was discharged by the area psychiatrist as it was assumed that follow up would be given by the rehabilitation team. A month later, Steven was readmitted under section as he had been walking the streets with live ammunition.
Ask Yourself.....
- How many young people with psychosis (under 25 years) hove continuing key worker contact, even when they are medication free/non-compliant?
- How many of them already have a key worker who has met the family before an admission?
- How many cases have been closed, with or without key worker allocation, when there has been a suspicion of psychosis; and how many are closed by "default", ie. the client closes or declines contact?
- What do you do when someone persistently declines your service?
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National Service Framework Links:
Standard 4 requires services to optimise engagement, using assertive outreach where appropriate; and to have a written care plan which includes action to be token in a crisis. This is to be undertaken within the framework of the Care Programme Approach.
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