NAVIGATING UNCHARTED WATERS – Towards a Personality Disorder Service For the Homeless Population in Glasgow

WHY TELL YOU ABOUT THIS?

Although a very particular service developed in response to local and specific demands • General principles may be helpful to consider • Something to learn from cross-agency working • Options for service design worth discussing • Welcome ideas about evaluating service

SETTING THE SCENE

GHN – approx 80 voluntary sector homelessness providers

SETTING THE SCENE

GLASGOW’S HOMELESSNESS STRATEGY • Closure of large hostels • Diversion from hostels • Provision of new services and accommodation • Development of new joint assessments • Reduction in repeat homelessness

Improving the Standard of Accommodation

• From this…..

To this.

Principles behind Design of Homelessness Services

• Based on health needs assessment • Establish known gaps in service • Identify issues around access, and consider this in design of service • Work in partnership with other agencies • Services ACCESSIBLE, FLEXIBLE, RESPONSIVE to NEED • Re-shape services as needed

OBJECTIVES for HOMELESSNESS SERVICES

• Improve access to services for homeless people • Reduce inappropriate use of A/E • Improve management and resettlement for homeless people with complex needs

MENTAL HEALTH DELIVERY PLAN

• Principle of equality and social inclusion • Better management of long-term conditions, including PD • Avoid inappropriate admissions Extracts from commitments and targets

HOMELESS HEALTH SERVICES

Homeless Mental Health Team Primary Care Mental Health Team GP Practice Homeless Families Service Physiotherapy Dieticians Podiatry Sexual Health Service HART Homeless Addiction Team (2007)

Integrated Homelessness Teams – (Health and Social Work)

Homeless Addiction Team 19 Health + 19 Social Work Staff (nursing, medical, OT, psychology) 1 Joint Team Leader Currently supporting 629 homeless people with addictions. Research on ARBD, assertive outreach model used and staged engagement.

Hostel Assessment & Resettlement Team To carry out complex assessments on hostel residents to provide alternatives and associated care packages Social Work / Housing and Health Staff (OT, CPN, Dietician)

Integrated Homelessness Teams

Assessment and Diversion Team

To assess presentations to homelessness and divert them away from hostel into appropriate support services/ alternative accommodation

•

Social work/housing, health (CPN, OT, dietician)

New Developments in Homeless Mental Health Service Since 2004

•

Discharge & Resettlement Team – resettle people from hospital prevent new homelessness reduce in-pt days

• • •

6 Dedicated in-patient beds Trauma Team Personality Disorder Team

PERSONALITY DISORDER and HOMELESSNESS TEAM

• Followed from gap analysis • Significant no. of institutionally homeless people – difficult to house, and needs not met by existing services • Many with history of complex trauma • Many thought to have PD, although this often not diagnosed • Many “held” by vol sector organisations

SERVICE MODEL

• Pragmatic choice; given circumstances • Room to develop and change • Learned from Edinburgh model • Bateman and Tyrer (2004) -SOLE PRACTITIONER -DIVIDED FUNCTIONS * -SPECIALIST TEAMS

SERVICE MODEL

• Specific remit to work across all agencies in homeless partnership; HEALTH, HOUSING, SW, VOLUNTARY SECTOR • City wide • Aim to

build capacity

in existing services • 1 consultant psychiatrist in psychotherapy • 1 adult psychotherapist/ group analyst

MODEL COMPRISES:

• Assessment and psychodynamic formulation, followed by consultation • Consultation only – patient not seen • Regular complex case discussion • Telephone advice/ liaison/ signposting • Training • Limited capacity for direct psychotherapy, Individual and group

FIRST YEAR

• 56 Referrals, 31 Seen directly 15 Consultation only 6 Pending/ disappeared/ prison/ died 4 Redirected immediately • Continuing effort to raise profile of team • Significant pre-referral discussion

SOURCE OF REFERRALS

• Statutory Organisations – 39 (70%) 22 of these from homeless services

2 6 31 North South East West

SOURCE OF REFERRALS

• Voluntary Sector – 17 (30%)

1 2 8 6 North South East West

ASSESSMENTS

• 138 appointments Attended 67 (49%) DNA Cancelled 38 28 (27%) (20%) Not specified 5 (4% ) • Extra efforts required to track and engage patients • Frequent liaison with other services

DIAGNOSIS

14 12 10 8 6 4 2 0 0 PD 1 PD 2 PD 3 PD 4 PD 5 PD

Other Diagnoses: Mild LD, Primary substance misuse problem, Generalised anxiety disorder

TYPES OF PD

16 14 12 10 8 6 4 2 0 Bord Diss Dep Imp Par Anan

CONSULTATION

• Number: 115 • Efforts made to include all involved agencies • Model welcomed by vol sector agencies/ housing providers/ social work • Health agencies prefer “taking” the patient • Advantage in piggy-backing onto CPA or Vulnerable Adults procedures

ROUGH SEAS

• Finding language to formulate simply • Translating into practical advice • Getting multiple workers/ agencies to buy into model • Information sharing across agencies • Sheer effort of constituting meetings • Idea of “own tenancy” as a goal for all

DIRECT TREATMENT

• Whether such a small service can provide direct treatment?

• Model of 1x individual + 1x group • Mentalisation based focus • Would require good links with all those involved in care – good case management • Would require reasonable degree of stability

TRAINING

• 1 Day Introduction to PD training • Constantly under review • Mixed groups vs tailored training to one organisation • Focus on boundaries • Attention to different learning styles • Move from theoretical to more interactive/ experiential

DRAFT I.C.P. for BPD

There needs to be a generic training programme to promote EMPATHY, RESPECT and implementation of the principles of management for

all

staff… PRINCIPLES: • Establish alliance while managing risk • Maintain flexibility • Establish conditions to make pt safe

DRAFT I.C.P.

• Tolerate intense anger/ aggression/ hate • Promote reflection • Set necessary limits • Understand the dynamics and monitor relationship; reducing poss. splitting • Monitor C/Tr feelings • Use a consistent approach

HOW TO EVALUATE???

Main outcomes likely to be difficult to measure; • Reduced staff stress levels • Less staff turnover • Better maintenance of boundaries • Not doing harm • Very slow change in level of chaos e.g. tenancies held/ less A/E presentations