Eastern Birmingham Multi Agency MDT Model Primary Care

Eastern Birmingham Multi Agency MDT Model

Primary Care Liaison Model

Who are we? • • GPs from Omnia and Druid Group practices (E 5)) East Hub Community Mental Health Team – Riverside Birmingham Healthy Minds Birmingham Community Health Trust Birmingham City Council – Social Care team Birmingham Mind Better Pathways Living Well Consortium

Our aim • To develop a place based primary care mental health liaison model built around a multi organisation MDT. • To provide GP facing support via screening and or multi agency triage of patients’ needs, provision of short term interventions and or specialist advice and signposting. • To work as one team ensuring joined up communication and timely effective support and case management.

Why we are making a difference “My view is that the pivotal issue that makes or breaks the process is the individuals who come from the organisations. We now know each other, respect each other, understand better each other’s service offers and constraints and most importantly have built trust. That cannot be mandated in a service specification but is what makes it tick”. Dr Peter Thebridge – Omnia practice “The MDT style of working has given me a new insight into understanding mental health in the context of employment, housing and relationships. I also am now beginning to understand the many different organisations who are doing great work and are able to help in these areas. Often as GPs we are isolated in our consultation rooms and this is a great opportunity to understand our patients’ problems on a more real level, and how to go about tackling some of the root causes of adverse health”. Dr Daya Chandan - Druid group practices

Case study 1 Joint working between GP, Home Treatment and Birmingham MIND creates a holistic approach Male aged 32. Moved from another city following divorce and is now living with sister. Suffering from depression and isolation and not leaving the house. Under care of Home Treatment and near admission. MIND contacted the patient who asked MIND to go through his sister as he was not confident with English speaking and too unwell. MIND discussed with the sister the types of things he would enjoy such as physical work, building and gardening and built strong rapport.

Case study 1 continued Opportunities were shared including Small Heath Community Forum, Green Lane Mosque and Nishkam Centre. Patient is now much better; venturing out every day with friends and family. Sister is positive and happy to have brother nearly back to old self. Sister and patient commented that they would contact MIND for future advice & guidance.

Case Study 2 37 year old male, discharged from local CMHT, a period spent in prison, no violence reported. Visited GP to request help with housing and employment issues. Discussed at MDT and referred to Better Pathways. Contact made and forklift truck driving course arranged and attended. On completion he will be offered work experience and support in finding a job. At a return visit to the GP he commented how helpful the support had been from Better Pathways.

Case study 3 60 year old lady under secondary care services, suicidal, seen by liaison psychiatry and HTT. Discharged back to GP in Dec. Given contact details for BHM by GP. Husband died, feeling depressed and lonely, keen for further treatment. Birmingham Mind and Living Well offered support. Help with benefits confirmed and Living Well successfully made contact for a telephone assessment, followed by treatment delivered by several phone and face to face sessions.

Case Study 4 A 51 year old lady with a chaotic history, on the zero tolerance register, under Small Heath CMHT, also known to Birmingham City Council. Refuses to engage and won’t take medication. Regularly contacts street triage and liaison psychiatry. No mental illness diagnosed. Accommodation problems, has set fire to her property in the past. Has a social worker. Requesting for someone to have a cup of tea with her once a week (social isolation).

MDT actions: Multi agency meeting arranged by the social worker. Discharged from CMHT as no mental illness diagnosed. Recently arrested by the police and appeared in court. Better Pathways and social care to offer support. Referred to BHM. Housing team unable to move her due to anti-social behaviour. Attending sessions run by Creative Support although she does not engage but turns up for refreshments and expects staff to take her shopping. Floating support applied for but no response to date. Difficult case to solve – possibly needs a befriending service?

Benefits of collaborative working through the MDT meeting • Building better relationships across primary, secondary and community services • More joined up multi-agency support • Holistic approach focused on the person • Able to navigate to relevant local services and support groups • Sensitive to what has and has not worked before – determined to break the cycle and/or offer something new • Ability to respond in short time frames

Outcome measurement and reporting Key Principles • Person-centred • Focus on recovery and the service user experience • Holistic Quarterly dash board of numbers e. g. • Cases reviewed by primary need, age, gender, ethnicity and disability • Cases referred to each MDT partner and other services • Cases with multiple partners involved in care • Cases directed to right place first time • Cases diverted away and stepped down from secondary care

Bi-annually: • Deep dive into a selection of cases to understand needs, effectiveness of response, impact and outcomes of interventions for the service user and the wider system, service user experience and how to improve the offer • Survey of clinical stakeholder views – confidence, responsiveness, appropriateness and trust and how partner participation should develop Annually • Assessment of team working and MDT effectiveness (Aston Business Management) • Telephone survey of a range of service users (who engaged and did not engage) to capture feedback