The home team

admissions, with most clients receiving care at home. Graham Stokes and colleagues explain

A new mental health service for elderly people living in south- east Staffordshire began to take shape four years ago. The phased closure of St Matthew's Hospital, a traditional psychiatric institution on the outskirts of Lichfield, presented the opportunity.

The aim was to develop a model cost-effective service for a mixed urban- rural population.

In 1993, for a population of approximately 31,000 adults over 65 years old, Premier Health provided 47 acute admission and assessment beds and 62 continuing care beds. The community service consisted of psychiatric nurses and social workers doing traditional weekday office hours in three locality community mental healthcare teams for older adults (three community psychiatric nurses, one healthcare assistant, one social worker, one community care worker per team).

An audit of admissions found that many referrals to acute inpatient beds were for social care breakdown, not specialist clinical assessment and treatment. As inappropriate hospital admission is generally considered damaging, it was decided to move towards a service which could support older people at home.

A service model that quantifies expected demand was piloted drawing on research.1,2 It was evaluated by York University's health economics consortium and rolled out through the trust in 1995. The principles of the model are:

A successful service depends on following a managed care pathway (see box) that identifies discrete service steps, expected outcomes and defined quality standards.

Assessment must be community-focused. All referrals must come through the CMHT. All professionals required in the process of assessment and the delivery of care are represented on the CMHT (nursing, occupational therapy, physiotherapy, psychiatry, psychology and social work).

Potential clients are initially seen at home by a team member of any discipline, who conducts a screening assessment. The effectiveness of direct referrals to CMHTs and assessments conducted by professions other than psychiatry is well documented. After a multiprofessional review of the initial assessment, either there is a further assessment at home by the appropriate team professionals, or the client is admitted to hospital.

The most likely outcome is the delivery of a care package. The healthcare assistant, a supervised, unqualified hands-on practitioner, is central to this type of service. They observe clients in their daily lives and contribute to assessments. They provide support at the time of discharge from hospital and give continuing care in the client's home. They also help the client get into community networks.

The screening assessment is conducted within a standardised protocol and completed at the CMHT review. The screening investigation is not diagnostic, but detects problems in mental functioning, mood, activities of daily living, health, physical and sensory abilities, challenging behaviour and carer well-being. The favoured option is treatment and continuing care at home.

The service is not consultant-led or driven. This is consistent with developments elsewhere.2 Rather, the consultant psychogeriatrician is seen as a key member of the CMHT.

A traditional doctor-led service, in which every patient is seen and assessed on a domiciliary visit or in an outpatient/day hospital clinic, is inappropriate for the disorders seen in an elderly mental health service, in which psychological, social and functional disabilities feature alongside psychiatric problems.

The staffing of the service consists of (whole-time equivalents) one consultant psychogeriatrician, two staff-grade psychiatrists, 12 community psychiatric nurses, 21 healthcare assistants, five social workers, 1.5 occupational therapists, one physiotherapist, 0.6 consultant clinical psychologists. We plan to increase numbers of staff in all these categories.

We aim to maintain sufficient beds to support the community service. But at the end of 1994 we began a dramatic reduction in beds. By 1995 we had cut back to just 12 beds for elderly people. It was envisaged that a community service providing assessment, routine and crisis treatment, and care at home throughout the week and out of hours, would markedly reduce the need for admissions. A managed care pathway was introduced to complete the service.

Over the past four years there has been a 72 per cent increase in referrals but a 10 per cent drop in admissions. In 1996-97 15 per cent of referrals led to an admission. Our aim is an admission rate of 10 per cent. The increase in length of stay is probably due to changing case-mix (ie, greater severity) and the funding limits on social services for residential and nursing home care. Our objective is to achieve a median length of stay of 20 days.

Our service does not adhere to the archaic '65th birthday' criterion of entry to an elderly mental health service. Adult psychiatry remains involved in the treatment of the 'young-old' and elderly graduate patients. A few elderly referrals (10 per cent) go through adult psychiatry. There is a progressive move away from this referral path (down 39 per cent in three years), which is desirable, as to be referred through adult psychiatry increases the likelihood of admission by a factor of nearly three. This may reflect case severity or, more likely, the absence of the managed care pathway and community infrastructure available to the elderly CMHTs. The outcome is a total acute bed requirement for older adults of 14 (ie, 12 designated elderly beds, and access to two 'adult' beds), which represents a bed rate of 45 per 100,000 elderly population.

Typically the process of community assessment (patient contact, assessment and multiprofessional review, treatment and care plan, report to GP) is completed within five days of a referral being received. Overall, 97 per cent of cases are assessed, reviewed and care programmed within 15 days of referral.

Premier Health has achieved a radical reorganisation of its mental health service for older adults. Operating in the communities where people live, it provides an efficient and responsive service to the needs of both patients and the primary healthcare teams.