CRISIS MANAGEMENTAT THE

MANAGED CLINICAL NETWORK

Aims• Outline crisis management

‘framework’ at MCN

• Highlight contributing factors in developing a shared understanding

• Outline evaluation project

Service Criteria

• Diagnosis of personality disorder or identified personality difficulties

• Multiple ‘complex’ needs

• Significant risk, particularly to self

• Poor response to previous treatment

• Limited social network

• Difficulty maintaining contact with services

• 18 and above

MCN Care Co-ordination• Up to 100 weeks clinical case management

• Small case loads

• Assertive approach

• ‘Intensity’ titrated to stage of treatment

• Safety & Containment

• Control & Regulation

(A Simpson, C Miller & L Bowers, Journal of Psychiatric and mental Health Nursing, 2003)

Service User

Involvement

Accommodation

Individual Psychology/Psychothera

py

Group Work Programme

s

HCSW Support

Pharmacy Input

Occupational Therapy

Care Co-ordinator & Service User

3rd Sector Parties

Inpatient TeamsCrisis

Resolution home

treatment team

Family & Carers

Key Challenges

• Significant number of inpatient admissions

• Significant degree contact CRHT team & police (S136)

• How to manage ‘splitting’ across services

• How to embed ‘general therapeutic strategies’

• How to balance immediate safety with treatment goals

Crisis Management Framework

Principle: ‘Relief comes from having a connection with someone who understands’

Goals• Support service user to ‘contain’ distress• Prevent an escalation• Support service user to return to the previous level of functioning as

quickly as possible• Respond in a way informed by a formulation• Avoid a service response which escalates distress or reinforces

maladaptive behaviours

Therapeutic Stance• Align with the patient’s distress

‘Containing’ Interventions• Convey support and understanding• Establish a connection with the service user• Focus on affect rather than content• Use straightforward, concrete statements that reflect an understanding of

the current situation and the patients’ experience• Reinforce the service users strengths and self-management skills• Set limits supportively• Arrange additional support (e.g. MCN team, CRHT)

(Practical Management of Personality Disorder – John Livesley 2003)

Crisis Plan Template

What might be helpful to know about my past?

What is a crisis to me ?

Events that can lead to a crisis / triggers

What can help if I feel like this?

What does not help / makes things worse?

If I need support, how and where do I get it?

Helpful thoughts to keep in mind

How can people help me to use this plan

Who has contributed

Emergency contacts

A Shared Approach, What Helps?

• Crisis plan framework

• Formulation informed crisis plans

• Crisis plan developed with service user and key ‘partners’

• Guidance for admissions incorporated into CPA care plans

• Practice development lead role

• Consultation

• KUF training

• ‘Specialist’ services

• Development of ‘whole systems pathway’

WHOLE SYSTEMS PATHWAY

Offer immediate containing interventions

Service user first point of contact in a potential crisis:- PDCN, CRHT, DSHT, A&E

Assess risk - Refer to current FACE risk assessment and CPA

crisis management plan

Risk remains unacceptably High

Try other treatment options:

• Involve family/carers• Increase visits • Use alternative community

services – Dial House, Connect etc

Risk remains unacceptably high

Hospital admissionWard interventions should provide safety, structure, consistency and increased contact/inputRefer to CPA care plan if appropriate

Clinical reviews with Network Coordinator should take place within 48 hours of admission wherever possible

What does the service user want:

Relief from distress

Risk remains unacceptably High

Contact CRHT triageInitiate joint assessment

whenever possible

Home treatment

ACS

Discharge planning to involve care co-ordinator, ward team and service user

Crisis Plan Evaluation

Project team;• Mike Pearce, Practice Development Lead• Vicky Green, Care Co-ordinator• Vicky Baldwin, Education & Practice Consultant• Jamie Scott, Clinical Team Manager

Project AimTo evaluate the impact of the development of collaborative crisis plans between Crisis Resolution Home Treatment (CRHT) & Personality Disorder Clinical Network (PDCN) staff and service users currently engaged in care co-ordination at the PDCN.

• change in service user’s self assessed capacity to manage ‘crisis’ effectively

• change in service user’s experience of PDCN & CRHT teams in responding to ‘crisis’

• change in staff’s self –assessed knowledge, attitudes and skills

• change in amount and type of contact with ‘out of hours’ services

Inclusion criteria• All service users engaged in the care co-ordination intervention (September

2011) (sample size 20)

Process

Produce Evaluation Report

Collect comparative service use data

(September 2012)

Post crisis plan questionnaire (September

2012)

Crisis plan review meetings

Crisis plan completed with care co-ordinator and a member of the CRHT team (October

2011)

Pre evaluation

period questionnair

e (September

2011)

‘When written in Chinese, the word CRISIS composed of two characters, one represents danger, the other opportunity’

John F Kennedy

• Any Questions?