Case Study on Service User with Complex Health and Social Care Needs

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The aim of this assignment is to critically explore and focus on a service user with complex health and social care needs. Firstly, the author will critically review and explore the theory of case management and what is meant by the term complexities in health and social care. The author will then briefly introduce their identified service user then critically evaluate their health condition. The author has identified the organisation of a mental health act assessment as an important episode of care in relation to their identified service user, in addition, the author will critically discuss the role and responsibilities of the nurse and other professionals of the multidisciplinary team in prioritising and managing the complexities involved in the service user’s care. To support the rationale behind choosing this identified service user is that the author of this assignment was involved in this complexed episode of the service users care, plus, it was a new experience which assisted the author in identifying the different roles of the multidisciplinary team. Finally, a conclusion will be provided at the end of the assignment to identify and discuss what the student nurse has learned from undertaking this assignment. In line with the Nursing and Midwifery Council [NMC] (2015) The Code: Professional standards of practice and behaviour for midwifes and nurses, no mention will be made to the identity or location of any person or establishment, for confidentiality purposes the pseudonym John has been given to identify the service user.

This episode of care was with an Adult Community Mental Health Team (CMHT) setting. The main objective and purpose of Community Mental Health Teams is to facilitate and provide specialist care to people in the community (Department of Health, (DH) 1999, 2000; World Health Organization, 2007). These multidisciplinary teams (MDT) have the responsibility to make collective, consensuses decisions that address the biopsychosocial perspective and the personalised case management for the individual service user (Belling, Whittock, McLaren, Burns, Catty & Jones, 2011; Twomey, Byrne & Leahy, 2014; Vitale, Mannix-McNamara & Cullinan, 2015).

Case management has developed as the underpinning principle of all community mental health services (Gilburt, Peck, Ashton, Edwards & Naylor, 2014). The case management framework for mental health services in the United Kingdom is known as the Care Programme Approach (CPA) (Kelly, 2013; Lester & Glasby, 2010). The CPA owes its origins to the intensive case management theory which is based on the seminal rehabilitative approach advocated by Anthony and Buell (1974), their rehabilitative approach was focused predominantly at developing goals that were based on the individual’s strengths, these strengths then would assist in the prevention, deterioration and reoccurrence of the mental health disability (Challis, Hughes, Berzins, Reilly, Abell, Stewart & Bowns, 2011; Corrigan, Mueser, Bond, Drake & Solomon, 2012).

The CPA was designed, introduced and implemented in the 1990s, its implementation was problematic, slow and obstructed by complications at a strategic level (Jones, Orrell & Hughes, 2010; Thornicroft, 2011), as the Department of Health (DH), National Health Service (NHS) and Social Service organisations attempted to incorporate and integrate the community care act and the CPA, the intention was that these systems would be fully integrated to provide multi-agency and multidisciplinary care for people with mental health problems (Gilburt, Peck, Ashton, Edwards & Naylor, 2014; Ham, Dixon & Brooke, 2012). However, the lack of integration resulted in excessive bureaucracy and other barriers that hindered effective joint working (Hannigan & Coffey, 2003).

Due to past inefficiencies of inadequate interagency collaboration, concerns were raised regarding the capability to care or manage people with complex mental health problems in crisis (Gilburt, Peck, Ashton, Edwards & Naylor, 2014; Rees, Iqbal & Backer, 2014), high profile cases such as Christopher Clunis, who stabbed a stranger to death at a London tube station (Coid, 1994) and Ben Silcock, who climbed into the lions enclosure at London Zoo (Hallam, 2002) resulted in identifying and highlighting that the community care being provided was failing and was inadequately implemented (Cummins, 2011; Turner, Hayward Angel, Fulford, Hall, Millard & Thomson, 2015). The Ritchie Report (1994) directed the renewed drive to make the CPA an effective component in the provision of mental health care. Because of these enquiries, the government identified mental health as a clinical priority (Bosanquet & Kruger, 2003; Rogers & Pilgrim, 2001). The White Paper Modernising mental health services (DH, 1998) and the National Service framework (NSF) for mental health (DH, 1999) identified standards that required improvement in five areas of care such as primary care, access to services for individuals with severe and enduring mental illness, mental health promotion, suicide prevention and caring about carers (Bhui, Stansfeld, Hull, Priebe, Mole & Feder, 2003; Rogers & Pilgrim, 2001). Cohen and Galea (2011) state that the launch of the No Health, Without Mental Health document (DH, 2011) was the first white paper strategy which identified that physical and mental health are both interlinked, Mockford, Staniszewska, Griffiths and Herron-Marx (2012); Scheirer and Dearing (2011) also emphasise that by introducing mental health into the public health agenda truly demonstrated how significant and important public mental health is in the UK.

The DH consultation document Reviewing the Care Programme Approach (2006) recognised and acknowledged that the CPA had become an administrative office tool that led to a tick box mentality rather than a process used for case management, supporting crisis planning and risk assessment (Williams, 2013). Subsequently, Refocusing the Care Programme Approach (DH, 2008a) ensured that unnecessary bureaucracy was removed and that organisations and services should work together and adopt approaches for integrated service delivery, plus, the revised guidance enforced that the CPA will only apply to those with identified complexed needs, so, in contrast the UK currently has one level CPA (Norman & Ryrie, 2013; Pryjmachuk, 2011).

However, Boaden, Dusheiko, Gravelle, Parker, Pickard, Roland and Sheaff (2006); Davies Williams, Larsen, Perkins, Roland and Harris (2008); Russell, Roe, Beech & Russell (2009) argued that although CPA’s have the potential to deliver better care for patients they must be well designed and be embedded in a wider system that provides, supports and values the complexities of co-ordinated care. Allen, Balfour, Bell and Marmot (2014) state that complexities in care can be identified and associated with various social, economic, and physical environments that operate at different stages of life, these biopsychosocial complexities and factors are comprehensively correlated with social inequalities (Bell, Donkin & Marmot, 2013), the greater the social inequality then the higher risk of mental and physical disorders (Bambra, 2010; Campion, Bhugra, Bailey & Marmot, 2013).

John was a 33-year-old male, who lived alone. John had a pre-existing diagnosis of delusional disorder accompanied by a diagnosis of mental and behaviour disorder due to use of excessive alcohol. Delusional disorders have been identified as a sub category of psychosis and schizophrenia by National Institute for Health and Care Excellence (NICE) (2014a); The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM) (2013); The World Health Organization’s (WHO) International Statistical Classification of Diseases (ICD) (2012). John held the fixed belief that he was being targeted by people in the local area, he also believed that there was a secret held in his DNA that related him to the Queen and was heir to the throne. John had a history of drug and alcohol abuse, it was identified that when under the influence of alcohol John becomes aggressive, John managed this aggression by only drinking at home to minimise contact with others. John had a police marker against him for violence due to his presentation when intoxicated.

Delusional disorders are often accompanied and characterised by psychotic behaviour, where the individual’s perception, mood, behaviour and thoughts are significantly altered (Butcher, Hooley & Mineka, 2015; Wustmann, Pillmann, Friedemann, Piro, Schmeil & Marneros, 2012). The symptoms of psychosis and schizophrenia can be divided into two key domains of positive and negative symptoms (Blanchard, Kring, Horan, & Gur, 2010; Wallwork, Fortgang, Hashimoto, Weinberger & Dickinson, 2012). The identification of positive and negative symptoms dates back to seminal work by Kraepelin (1919) and Bleuler (1950) both identified and highlighted the significance of positive and negative phenomenology in psychotic disorders. They identified the Dementia Praecox as a neurologic disorder that has an early onset in the adolescent period of human development and is associated and characterised by symptoms such as intellectual decline, disordered thinking, delusional beliefs, hallucinations, functional paralysis and early demise. Research by Emsley, Rabinowitz and Torreman (2003); Levine and Rabinowitz (2007); Wallwork, Fortgang, Hashimoto, Weinberger and Dickinson (2012) identified that in the absence of a biological marker, the diagnosis of schizophrenia solely relies on the assessment of the individuals mental state through clinical observation and interviews, the positive and negative syndrome scale (PANSS) designed by Kay, Flszbein and Opfe (1987) best captures and describes factors and symptoms that consistently emerge in the diagnosis of schizophrenia other psychotic disorders.

Cohen, Kim and Najolia (2013); Malaspina, Walsh-Messinger, Gaebel, Smith, Gorun, Prudent and Trémeau (2014) state that positive symptoms form the direct manifestation of the psychopathological process, positive symptoms can include persecutory or grandiose delusions, along with hallucinations that are visual, auditory, olfactory, gustatory or tactile. Australian (2017); Foussias & Remington, (2010); Kendall, Hollis, Stafford & Taylor (2013) emphasise that the negative symptoms form the symptoms of reactive and compensatory psychological manifestations which include social withdrawal, self-neglect and emotional apathy. Harmful drinking and increased alcohol consumption contributes significantly to the increased rates of mental and physical disorders (NICE, 2014b), the severity of alcohol misuse is important as it determines the level of treatment required (Butcher, Hooley & Mineka, 2015; Lubman, King & Castle, 2010). NICE (2014b) state that acute withdrawal from alcohol in people with complex comorbidities if not managed properly can lead to seizures, delirium and in extreme cases sometimes death. Buchanan (2007); Insel (2010); Tandon, Nasrallah and Keshavan (2010); Ventura, Wood and Hellemann (2011) all emphasise that every individual suffering with or from a form of psychosis and schizophrenia will have a unique combination of different symptoms and experiences.

NICE guidelines (2014a) state that the course of psychosis and schizophrenia varies considerably, although, studies by Fischer and Buchannan (2012); Morgan, Leonard, Bourke and Jablensky (2008) found that there is an identifiable common pattern. Fischer and Buchannan (2012) state that typically, there is a prodromal period, an early symptom or sign of deterioration in personal functioning that indicates a first episode of psychosis that may last days to months. Bora, Erkan, Kayahan and Veznedaroglu (2007); Wustmann, Pillmann, Friedemann, Piro, Schmeil and Marneros (2012) emphasise that individuals may experience symptoms briefly or experience the symptoms for years, unfortunately the disorder can begin suddenly with an acute episode. Pioneering work by Birchwood and Macmillan (1993) discovered the stress vulnerability model promoted and advocated by Zubin and Spring (1977) does identify that a combination of internal biological and external psychological factors culminates in hastening and maintain psychotic symptoms.

Evidence provided by Abel, Drake and Goldstein, (2010); Fischer and Buchannan (2012); Grossman, Harrow, Rosen, Faull and Strauss (2008) suggested that sex differences, neuro development and social factors all contribute to the disease risk and course of psychosis and schizophrenia. Research by Hor and Taylor (2010); Wobrock, Falkai, Schneider-Axmann, Hasan, Galderisi, Davidson and Libiger (2013) identified that the age of onset is characteristically and quite often during adolescence, young males on average between the ages of 18 and 25 are diagnosed with schizophrenia, substance abuse was identified as a predominant factor and activity in this group.

Epidemiological data and studies related to the incidence and prevalence of schizophrenia have identified that the prevalence of schizophrenia is in the range of 1.4 to 4.6 per 1000 and the incidence is in the range of 0.42 per 1000 people (Bebbington, Rai, Strydom, Brugha, McManus & Morgan, 2016). The prevalence of schizophrenia affects more than 21 million people worldwide (WHO, 2016). Research by Brown, Kim, Mitchell and Inskip (2010); Kirkbride, Fearon, Morgan, Dazzan, Morgan, Murray and Jones (2007); McGrath, Saha, Chant and Welham (2008) suggests that the prevalence and incidence of schizophrenia is higher in the population that live in urban areas and is greatly influenced by social capitol and ethnicity.

McCrone, Dhanasiri, Patel, Knapp and Lawton-Smith (2008) state that recent estimates for schizophrenia identified that the costs of mental health service provision in 2007 was around £2.2 billion, along with these projected estimates, the cost could rise to £3.7 billion by 2026. However, later studies and research by Knapp, Beecham, McDaid, Matosevic and Smith (2011); Royal College of Psychiatrists (RCPSYCH) (2014); Trachtenberg, Parsonage, Shepherd and Boardman (2013) discovered that when the costs of lost employment were added to the mental health service provision the figures significantly increased to £4.0 billion for 2007, along with the projected increase to £7-8 billion by 2026. The RCPSYCH (2014) state that by understanding the dissemination and determinants of psychosis and schizophrenia is crucial when planning public health policies that promote the delivery of effective integrated mental health care. The Schizophrenia Commission (2012) recommend that the main aim of services should be to empower and educate as well as encourage self-management and choice.

Research by Kreyenbuhl, Nossel and Dixon (2009); Lester, Marshall, Jones, Fowler, Amos, Khan and Birchwood (2011) discovered that disengagement from mental health services is a significant problem which leads to destructive and damaging consequences, disengagement contributes to an exacerbation of psychiatric symptoms, repeated hospital admissions, violence against others, and increased rates of suicide (Dixon, Goldberg, Iannone, Lucksted, Brown, Kreyenbuhl & Potts, 2009). Conus, Lambert, Cotton, Bonsack, McGorry and Schimmelmann (2010); O’Brien, Fahmy and Singh (2009) state that rates of disengagement from mental health services varies from 4% to 46% depending on sociodemographic predictors such as age, ethnicity and deprivation, plus, research by Bergé, Mané, Salgado, Cortizo, Garnier, Gomez and Pérez (2015); Stowkowy, Addington, Liu, Hollowell and Addington (2012) found that clinical variables such substance misuse, lack of insight, forensic history and service provision also contributed to disengagement,  all these factors and variables can and should be used to explore the association of the illness, the difficult to reach patients and service provision. However, a recent systematic review of literature by Clement, Schauman, Graham, Maggioni, Evans-Lacko, Bezborodovs and Thornicroft (2015) discovered that stigma along with disclosure concerns was an overarching key deterrent in seeking help for mental health problems.

This part of the assignment allows the author to critically review the responsibilities and roles of the nurse and other members of the MDT and discuss the chosen intervention.

The chosen management intervention was the coordination of a mental health act assessment (1983). The MHA 1983 which was amended in 2007 is the law in England and Wales that allows for the detention and compulsory treatments of individuals suffering from a mental disorder, it warrants the provision of treatment in the interest of their own health or safety or for the protection of others (Maden & Spencer-Lane, 2010; Stuart, 2014; Townsend, 2014). Lester and Glasby (2010); Norman and Ryrie (2013) state that section 3 of the MHA provides compulsory admission for treatment for up to six months, this can be renewed for a further six months. The 2007 act also introduced the Mental Capacity Act (2005), this act applies to people over the age of 16, it provides a legislative framework to protect and empower individuals who lack capacity to make decisions for themselves (Pryjmachuk, 2011; Thornicroft, 2011).

In context, prior to the implementation of the mental health act assessment John’s care coordinator had been visiting John in the community frequently. The care co-ordinators role is central to the CPA (Hannigan & Allen, 2011) and in most cases often employed or held by the community psychiatric nurse (CPN) (Stuart, 2014). The importance and complexity of the role regarding the care co-ordinator cannot be underestimated (Goodwin & Lawton-Smith, 2010), the complexity of the role can be, and is often reflected in the complexity of care plans (Huxley, Evans, Munroe & Cestari, 2008). The Mental Health Commission (2006) emphasise that by assigning a care coordinator can only promote high standards of care and is associated and identified as best practice in the delivery of mental health services.

During recent home visits, there were identifiable relapse signatures that were documented in Johns care plan, Farrelly, Szmukler, Henderson, Birchwood, Marshall, Waheed and Thornicroft (2014) emphasise that CPA care plans should include a crisis and contingency section that covers relapse and warning signs and plans for treatment. An important factor regarding the role of the nurse is to review and regularly update care plans (Pryjmachuk, 2011). Owen, Richardson, David, Szmukler, Hayward and Hotopf, (2008) highlight that relapses can be severe and consequently result in the individual lacking insight accompanied with a reduction in capacity, regarding these contexts, the individual inevitably loses trust in the nurse which adversely affects the therapeutic relationship (Farrelly & Lester, 2014; Katsakou, Bowers, Amos, Morriss, Rose, Wykes & Priebe, 2010; Sheehan & Burns, 2011).

An important component and factor of the nurse’s role is to maintain the therapeutic relationship, Norman and Ryrie (2013); Thornicroft (2011) emphasise that the therapeutic relationship is vital for engagement. Stuart (2014) and Townsend (2014) support this by stating the nurse – patient relationship has now evolved into the nurse – patient partnership, it is this partnership that expands the elements of the nurse’s role, these elements include clinical competence, communication, inter-professional collaboration and an awareness of legal and ethical dilemmas that develop when delivering mental health nursing care. However, although John’s nurse attempted to keep John engaged by organising and collaborating unsuccessful visits by the Crisis Resolution Home Treatment Team (CRHTT), plus, the deterioration,lack of insight and risks identified in John’s mental health and John’s reluctance to engage with services led to a review of John’s care with members of the MDT. CRHTT’s aim to provide rapid assessment in mental health crises and, where possible, to offer intensive home treatment as an alternative to acute admission (Johnson, 2013).  McQueen, St John-Smith, Ikkos, Kemp, Munk-Jorgensen & Michael (2009) state when faced with high levels of uncertainty and risk, an important factor regarding the role of the nurse is to seek advice from colleagues who have the competence and experience to support them.

To ensure a collaborative patient focused approach and to incorporate John’s perspective into any discussion or meeting, a person-centred approach had to be taken. It was the role of the Johns nurse to become an advocate for him, the NMC Code (2015) states a commitment to advocating the rights and needs of the individual is essential. Fairchild (2010); Fujiwara and Dolan (2014); Townsend (2014) emphasise that when healthcare is co-ordinated, integrated and focused solely on the individual then maximum benefits will be achieved. For care to be integrated and successful, care professionals need to bring together all the different elements of that have been identified in their care plan (Bower, Macdonald, Harkness, Gask, Kendrick, Valderas & Sibbald, 2011; Stafford, Jackson, Mayo-Wilson, Morrison & Kendall, 2013), however, if the plan is not based around the individuals needs or services are fragmented and difficult to access then the whole experience can lead to confusion, delay and individuals getting lost or even slipping through gaps in the system (Glover, Webb & Evison, 2010; Smith, Soubhi, Fortin, Hudon & O’Dowd, 2012).

Hall, Wren and Kirby (2013); Lloyd, King, Deane and Gourney (2009) state that when a number of professionals are involved in the provision of an integrated care approach, it is vitally important to identify a lead clinician who can coordinate, synchronise, communicate and provide all the relevant information, this leadership prevents role blurring and role confusion (Brown, Crawford & Darongkamas, 2000), role blurring has been identified as a barrier to effective teamwork (Fox, 2013;  Harmer, 2010), however, Hewitt, Sims and Harris (2015) emphasise role blurring  it is not necessarily a negative providing that individuals and teams communicate effectively, in relation to this case, there appeared to be no lack of communication.

Johns nurse initiated and maintained contact with the team’s consultant psychiatrist mainly by email and phone, Faulk and Savitz (2009); Polit and Beck (2008) state that technology such as computers, mobile phones and instant messaging has radically altered how the nurse now communicates and performs their work. Marquis and Huston (2014) emphasise that when used as a communication tool, technology has given the nurse the opportunity to access patient information instantly, this dramatically increases clinical decision making, documentation and team dynamics. This form of communication was highly effective during this episode of care, the nurse utilised organisational skills, by having to rearrange other visits he had on that day. The nurse explained that prioritising patients in crisis was key, and that communicating with other patients was extremely important so they were aware of when I would visit them next, and did not feel let down by cancelling their visit, the NMC (2015) state that the nurse must identify priorities and manage time effectively when dealing with those who’s needs and risk come first. However, Cherry and Jacob (2016); Potter, Perry, Stockert and Hall (2016) state it is imperative that the nurse finds a balance when utilising technology as a communication tool, technology cannot replace the need for human face-to-face interaction.

Research by Butterworth and Faugier (2013); Middleton, Glover, Onyett and Linde (2008) found that CMHTs are more effective when psychiatrists are fully integrated members of the team. Craddock, Kerr and Thapar (2010); Morgan (2007) emphasise that the consultant psychiatrist provides clinical leadership and fully understands the complexity of mental health provision, this understanding enables effective working between professionals from other specialities. However, research by Crossley and Lepping (2009); Iqbal, Rees and Backer (2014) highlighted that consultant psychiatrists can often make conflicting decisions that are contrary to decisions that have been made by other health professionals in the team, this undermining can lead to friction and have an impact on the nurse’s role, self-confidence and willingness to assert their professional judgement, which can lead to professional paralysis (Dale & Milner, 2009; Onyett, 2011).

After numerous emails and phone conversations it was decided under guidance and advice from John’s consultant psychiatrist that the best course of action and least restrictive option would be to co-ordinate a mental health act assessment to admit John to hospital for further assessment and treatment under section 3 of the mental health act (MHA) (1983). Bowers, Chaplin, Quirk and Lelliott (2009) state that when individuals run a high risk of harming themselves, or possibly harming others by disengaging from support, then admission to hospital for treatment and their own self-preservation is the most appropriate option.

The priority now was for Johns nurse to communicate and discuss all the relevant information with the on duty approved mental health professional (AMHP). The MHA (2007) introduced the role of the approved mental health professional (AMHP), The DH (2007) stated that these changes are designed to bring mental health legislation in line with other modern service provisions, the Care Quality Commission (2010) reinforce and support these changes after their review of the 2007 act by stating that these changes now allow a wide range of experienced and skilled professionals to take on more responsibility for patients, which contributes to broader professional perspectives. Coffey and Hannigan (2013); Laing (2012) state this role has proved to be effective as the input from a different mental health specialist provides expertise from a different perspective to that of the medical model, thus, providing a more bio-psychosocial perspective which contributes to effective holistic care.

The responsibility of coordinating the preliminary examination was assigned to the AMHP, Gostin, McHale, Fennell, Mackay and Bartlett (2010); Laing (2012) state when the AMHP is the applicant for detention they have the added professional responsibility to ensure that all the necessary relevant paperwork and arrangements are made to transport and admit the patient to hospital.

In conclusion, this assignment has examined a complex management intervention in the form of coordinating a mental health act assessment.

This case study has highlighted the roles and responsibilities of the nursing professionals involved in the management intervention, plus, it has also highlighted the skills required during a crisis situation within the mental health field. I have been able to acknowledge the importance of such skills such as effective communication, team work, autonomous decision making, organisational skills, decision making, crisis management and knowledge of key mental health legislation and law.

The case study has provided an insight of how important the care programme approach is when planning integrated care in respect of the service user with complex health and social care needs.

Word count: 4066.

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