As part of our support for Mental Health Awareness Week 2018, we spoke to Nicole who is an occupational therapist working for a community mental health service in West Yorkshire.
We asked her what it’s like to work in mental health, the challenges she faces each day and how she could benefit from electronic access to patient records held by different care providers.
I’m an occupational therapist working for an intensive community service in West Yorkshire. It’s a seven day service open from 08.00- 21.00.
We support people who suffer with acute mental health illnesses and at high risk of harm to themselves or others. Our role is to provide additional intense support to prevent service users from a psychiatric admission or to facilitate early discharge and support them in their transition back into the community.
The core team includes psychiatrists, junior medics, occupational therapists, mental health nurses and health support workers. We also work with a wider multidisciplinary team of pharmacists, dietitians, physiotherapists and other healthcare professionals.
Reviewing the daily caseload
My day varies depending on the caseload. When I first arrive we divide up the caseload and ensure each service user is allocated a key worker for the shift. Typically I’m allocated between six and 12 service users and have between three and four visits a day. This is often subject to change as we may need to move visits in order to address any additional crises.
Once I know my caseload for the day I will read their case notes to find out about their current presentation and what support is required to meet their needs that day. At this point, I may also phone or email external services to gather additional information, which can be time consuming.
Having read up on each patient I will share this information in the daily multidisciplinary team meeting. We use these meetings to discuss potential risks and review the patient’s progress through our service.
Visits are in hourly slots but the duration of each visit varies depending on the acuteness of the services users’ presentation, needs and their level of engagement. The hour includes travel time and if you’re fortunate enough to have your visits close together then you can have around 55 minutes with the service user. On other occasions, I have to travel from one side of the catchment area to the other, which leaves less than 40 minutes with the service user, which really isn’t enough time.
Complex care in the community
The service supports many patients with multiple, complex conditions. Currently we’re supporting a service user with learning disabilities and has emotionally unstable personality disorder. The service user is insulin dependent and when stressed, they refuse to eat or take their medication. In the past this has led to the patient being admitted to hospital due to physical health concerns. My role is to liaise with the district nursing team, GP and at times the A&E staff to improve the service user’s physical health by supporting their mental health.
Sometimes we will be asked to support individuals with depression, who are unable to get out of bed and significantly reducing their nutritional intake. In this situation, we will look at what motivates them and collaboratively identify some meaningful goals to get them out of bed and improve their nutritional intake, which subsequently improves their physical health.
When a service user has dementia and we’re concerned about whether they’re able to live independently, I will carry out functional assessments of activities of daily living. This allows us to assess their ability to perform simple tasks safely, and whether additional equipment or support may be required.
We also treat patients who are experiencing psychosis which often includes auditory, visual, tactile and olfactory hallucinations. Quite often, this affects their concentration and mood, which makes every day activities difficult. My role is to assess their mood, level of functioning and any associated risks and work with them to develop comprehensive coping strategies in managing these hallucinations. I also provide feedback to the team about the effectiveness of their medication and any side effects, such as sedation, which may impair their level of functioning.
Once I have completed all my visits I will return to the office to write up my notes from memory into the PARIS system. Our team use a template, which includes information about their mental health presentation, risks, details of their current medication and their social and occupational performance. We have allocated time to write our notes at the end of the shift, as information must be documented that same day, but we very rarely have the full allocation of time due to the hectic nature of the role and unexpected changes in service user’s presentation.
Dealing with the unexpected
Due to the complex nature of the role and the broad spectrum of mental illnesses I face different challenges each day.
We receive lots of unexpected phone calls, which is difficult if you don’t know the service user and have limited access to their information. Given the multifaceted nature of mental illness, linked in with additional comorbid illnesses we require extensive information in order to develop a comprehensive and personalised treatment plan. If we had access to all relevant information, it would help us to manage the calls more efficiently, and subsequently help us to be more responsive to service user’s needs.
A lot of time you’re working blind
Although we can view mental health records held by the trust, gaining access to information from physical health and social services is much more difficult.
Unless you’ve had training on how to use the Summary Care Record, you will need to ask the administration team or the medics to access this information on your behalf. The admin work 08.00-16.00 Monday to Friday and the medics go home at 17.00, which makes it almost impossible to access the system beyond these working hours. A lot of time you’re working blind.
The on-call doctor has access to the Summary Care Record but they are very difficult to get hold of and are based in a separate location. You can spend a lot of time contacting the switchboard to request that they bleep them, and then waiting for them to respond. Quite often, we miss their return call as we may be out on visits or on another phone call, which causes further delays.
If a patient is admitted a physical health ward, we will call the ward to gather information on how they’re doing. Sometimes the nurses are unavailable to take your call or they don’t want to disclose the information over the phone due to confidentiality reasons. If we could access this information electronically, it would make things much quicker and easier.
As a lone worker I’m not allowed to visit a patient until I have reviewed an up to date risk assessment, which has been completed in the last 24 hours. Sometimes we will have to wait to receive this information from a different service, which can delay the visits and have a negative impact on the service user’s care.
Following the paper trail
We have service users’ who have transitioned to us from external services such as the wards, Child and Adolescent Mental Health Services (CAMHS), different trusts across the country and quite often from private health care providers. We can’t access their information electronically as it’s held in a different system. This means records have to be shared with us as paper documents.
Paper notes are still used for each patient. This includes current information such as drug charts, ECG printouts and cognitive assessments. It also stores historical information such as discharge summary letters from periods before the data was stored electronically on the current system.
When transitioning from other services within the trust, the notes are transported to us by taxi or trust transport and the admin team store the records in two big cabinets. Only the psychiatrists look at this data and that’s only if they require historical information which isn’t often. The cabinets tend to get in the way as it’s a small office
A lot of the time we will receive information by fax. This is also a challenge as we have to chase up the documents and they don’t always arrive due to the unreliability of the fax machine.
If everything was digitalised we could get rid of the cabinets and the fax machine, it would be one less job for the admin staff and it would remove the transport costs.
One in four suffer with ill mental health
The most enjoyable part of the role is being able to help others and I like to have face to face contact with the patients. As we provide a short-term intensive service, quite often we see people get well quite quickly. I enjoy being able to enable people with the skills and confidence to live an enriched life.
There’s a huge stigma attached to mental health and it’s prevalence is more than we realise with one in four people suffering with a mental illness at some point in their lives. I think it’s important that mental health is in the media as people need to be more aware and more accepting of it. They may one day suffer with it and negative stigma only acts as an obstacle towards recovery
There’s no need for people to be stigmatised for having a mental illness and Mental Health Awareness Week is a great way of re-educating the people on this issue.
How can we help?
The Medical Interoperability Gateway (MIG) provides a wide range of information about a patient’s physical health. This includes, problems, diagnoses, medication (current, past and issues), risks and warnings, procedures, investigations, blood pressure measurements, encounters, admissions and referrals.
It identifies all the services involved in a patient’s care and streamlines communications between them. This includes GPs, mental health, hospitals, social care and community care providers.
Being able to view this information provides healthcare professionals with a fuller picture of a patient’s medical background. This can help them to make informed decisions faster and supports care planning for long-term conditions and co-morbidities.
To find out more about how we help to integrate care services, please call 0845 601 2642 or email firstname.lastname@example.org