The Care Path - Secondary Care/Specialist Services

Older people with more complex needs may need help from specialist services. Specialist mental health services are now in place almost universally, have a community focus and tend to be organised around a community mental health team, which is headed up by an old age psychiatrist.

Although there is considerable local variation, national guidance advises that a comprehensive service includes at least: a community mental health team, hospital based assessment services and day hospital provision. Some areas limit themselves to dementia care only.

Older people who need support from specialist mental health services tend to have well established mental ill health, severe or chronic symptoms and complex needs. For people with dementia, other reasons include: where diagnosis is difficult, there is significant carer strain and/or the person is displaying severe challenging behaviour.

The services displayed on this screen are available in most areas. Remember, as before, they are illustrative. One or more of the services may be offered to an older person depending on their level and type of need.

Click now on each service to explore case studies or specific examples.

The Care Path - Secondary Care/Specialist Services

Specialist mental health services are now in place almost universally. Although there is considerable local variation national guidance advises that a comprehensive service includes at least: a community mental health teams, hospital based assessment services and inpatient and day hospital provision. Some areas limit themselves to dementia care only (Royal College of Psychiatrists, 2005).

Specialist services have a community focus, tend to be organised around a community mental health team and is headed up by an old age psychiatrist (Lingard and Milne, 2004).

Referral to specialist services is likely to occur when:

  • an older person may have mental health problems but no diagnosis has been made the diagnosis remains uncertain or symptoms are particularly complex
  • the person’s behaviour or emotional state is creating a risk to themselves or others e.g. a carer
  • the person’s behaviour or emotional state is such that their care arrangements are likely to break down
  • his/her problems are particularly complex or legal issues are involved e.g. issues of capacity to consent to treatment

Case example:

The following case illustrates well the kind of case that requires referral to specialist services:

John is 74 and lives with his wife Mary. He has always been a volatile person but as he has become increasingly physically disabled with arthritis he has become even more difficult. He can no longer go out to the pub which has done daily for years and is angry whenever Mary leaves to go shopping or run errands. In the last six months he has started leaving the house when Mary is out and not returning for hours as he has forgotten where he lives; he has been brought home by the police four times! He has also been leaving the gas on unlit and letting smoking cigarettes burn out at the side of his favourite chair. Mary is at the end of her tether. John denies he has a problem but his GP, who Mary persuaded to visit recently, thinks he may have dementia. A referral to the local old age psychiatrist is arranged.

Community Mental Health Team

Community Mental Health Teams for Older People (OPCMHT) are multidisciplinary and, as an ideal, should include the following members:

Old age psychiatrists conduct medical assessments of older people with mental health problems, prescribe medication, plan treatment and are often provide leadership within a CMHT. They run outpatient clinics, do domiciliary visits and have access to inpatient beds; they may additionally have access to day hospital resources.

Community mental health/psychiatric nurses deliver treatment and care plans, provide long and short term support to users and carers, monitor medications, conduct nursing assessments. They are often very effective communicators and tend to be experienced at managing users with challenging behaviours. They act as a bridge between the inpatient ward and community based care.

Occupational therapists (OT’s) facilitate rehabilitation enabling individuals to retain or recover independent living skills and build confidence. OTs assess a patient’s abilities to perform activities and design treatment programmes to increase their capability to tackle difficulties.

Social workers bring a social care perspective and knowledge base to the work of a CMHT. They have a duty to conduct SAP and carers assessments and can facilitate access to a range of social care services. They are independent of their health professionals colleagues; they often act as a bridge between the inpatient ward and community based care.

Approved Social Workers are specially trained social workers who have a duty to assess the needs of any person suffering from a ‘mental disorder’ considered to require compulsory detention in psychiatric hospital (under powers outlined in the 1983 Mental Health Act). There may soon be changes to this situation as there are legal proposals to extend the role to professional groups other than social workers.

Clinical psychologists aim to reduce psychological distress and enhance and promote psychological wellbeing by employing a range of psychological approaches and interventions. In an OPCMHT they work with a wide range of mental health problems including dementia, depression, challenging behaviour and anxiety as well as help with personal and relationship problems.

(Royal College of Psychiatrists, 2005).

The additional input of untrained staff, such as health or social care assistants can also be invaluable, and adequate administrative support is essential.

The core functions of a CMHT have been defined as: a single point of entry, the delivery of specialist assessment and care management, and a multidisciplinary service to users with more complex needs and their carers. They also facilitate access to a range of services for users and carers and provide training to staff in mainstream services.

The following illustrates a CMHT(OP) within a wider health and social care system:

The integrated CMHT

  • Police
  • Victims of Crime Support Services
  • Accident and Emergency Departments
  • Specialist NHS Mental Health Services for Older People

Other Specialist Mental Health Services

  • Home care
  • Befriending
  • Care Homes

Primary Care Services

  • GP
  • District Nurses
  • health visitors for the elderly
  • Community Health Projects.

Generic Secondary Physical Health Care

  • Geriatrictians
  • Day Hospitals
  • Intermediate Care Schemes

Voluntary Organisations

  • Advice agencies
  • Care Services

Generic Social Care Services

  • MOW
  • Homecare
  • Day Services
  • Care Homes

(Lingard and Milne, 2004)

CMHT’s characteristically cover an agreed sector, which is often defined geographically. Teams usually deal with the full range of mental disorders. There is an agreed route of referral in each area, with most referrals coming from primary care; social services, residential homes and family members also refer.

There is considerable variability in the size, make up and remit of OPCMHT’s across the UK. Within a larger team, there is scope for some subdivision of responsibilities or for specialisation. For example, each member of the team may be linked to an individual GP surgery or have links with one or more residential or nursing homes.

There is accumulating evidence that community mental health teams for older people offer effective interventions (Alzheimer's Society, 2007).

Memory Clinics

Memory clinics are for people with suspected dementia. They sit somewhere between primary and secondary care and tend to be run by old age psychiatrists. Their focus is diagnosis of dementia, assessment for treatment and monitoring (Alzheimer's, 2007).

Although they are popular some critics have argued that memory clinics divert scarce resources from more valuable integrated community based care.

Admiral Nurses

Admiral nurses are specialist dementia nurses, working in the community, with families, carers and supporters of people with dementia.

The Admiral Nurse model was established as a direct result of the experiences of family carers. Admiral Nurses are named after Joseph Levy, who had dementia. He was known by his family as ‘Admiral Joe’ due to his keen interest in sailing.

Admiral Nurses:

  • work with family carers as their prime focus
  • provide practical advice, emotional support, information and skills
  • deliver education and training in dementia care
  • provide consultancy to professionals working with people with dementia
  • promote best practice in person- centred dementia care

They are employed by local health care trusts; they are in short supply and are only employed by a relatively small, albeit increasing, number of trusts at present.

Quote from Diana Melly the wife of 80 yr old jazz legend George who had dementia:

You have to make a lot of changes in your life when caring for someone with dementia..... Practically I don’t leave him on his own for long. Talking to admiral nurses is getting me through this difficult phase and helping me face the future

Intermediate Care

Intermediate care refers to a range of integrated services which aim to:

  • promote faster recovery from illness;
  • prevent unnecessary hospital or care home admission;
  • support timely discharge from hospital;
  • maximise independent living; and
  • enable users to remain, or resume, living at home (Department of Health, 2002).

They tend to involve the provision of active therapy or treatment, are intensive and time limited (normally no longer than six weeks) and involve cross professional working with a single assessment framework, single professional records and shared protocols.

Services usually focus on (re)enabling older people to regain lost skills, and increase confidence in performing activities of daily living such as dressing. They consist of nursing and/or therapeutic support in a user’s own home with home care input and sometimes telecare and/or equipment. Support for the carer is also offered. Historically older people with mental health problems were excluded from intermediate care schemes. In recent years a number have been developed, including:

  • ‘rapid response teams’ to prevent care home or hospital admissions of people with dementia for ‘social’ reasons e.g. carer illness;
  • home care teams skilled in dealing with older people with mental health problems that can provide intensive input for a short period for users at risk of (re) admission to hospital;
  • intensive day or residential physical and social rehabilitation in day centres, care homes, or community hospital

Service Example

  • One innovative example of an intermediate care service has been rolled out in Portsmouth and East Hants. To address the problem of the widespread under-detection of depression in older people and to improve the support provided for people with dementia, intermediate care teams, are developing closer links with mental health services. In Portsmouth and East Hants, the community rehabilitation teams include mental health nurses, whose role is to identify and treat people as well as to provide support on mental health issues to other professionals in the team

  • Rehabilitation services offered to people with dementia following a hip fracture in one London borough resulted in the maintenance of, or improvement in, activities of daily living skills and in fewer admissions to residential care (Lingard and Milne, 2004).

Day Hospital

Day hospitals are a long standing component of old age psychiatry services in the UK. Their focus is on assessment and therapeutic activities, and they are generally looking to discharge patients elsewhere, either after an agreed period of attendance or once a suitable outcome has been achieved.

This distinguishes them from day centres who support users over the longer term. Also day hospitals are part of the NHS, whereas day centres are run by social services or the voluntary sector.

In practice, however, there is considerable overlap between the clientele of the two types of day service.

Day hospitals vary considerably, especially depending on the relative proportions of patients with functional disorders such as depression, and dementia. Many organise for these groups to attend on separate days as the type of programme appropriate to each may be quite different.

There is mixed evidence of the efficacy of day hospitals especially around whether they prevent inpatient admission to psychiatric care (Dementia UK, 2007).