Complex Recovery, Advice and Consultation Service

ContactClair Jones, Specialist OT/CRAC team leader
AddressUpton Lea, Countess of Chester Health Park, Liverpool Road, Chester CH2 1BQ

Cheshire and Wirral Partnership NHS Foundation TrustThe Complex Recovery Assessment and Consultation (CRAC) Service in Cheshire and Wirral works to enhance existing care pathways by utilising expertise and specialist skills in complex care management. The team also captures on-going audit data looking at detailed analysis of variance leading to prolonged or repetitive use of acute care.

The team works closely with commissioners and is represented at Western Cheshire and Wirral funding panels. In addition the team completes specific work to support the Integrated Provider Hub in Western Cheshire in managing the mental health budget.

The team currently concentrates on four areas; complex individuals utilising acute inpatient beds, discharge coordination for acute wards, out of area placements and Autism Spectrum Disorder diagnosis.

In 2012 a major bed utilisation review within Cheshire and Wirral Partnership NHS Trust identified that acute admission wards worked well for those needing acute care but that there were a group of people with more complex needs who tended to stay longer and where pathways to recovery were less clear. The Trust decided to build on the successful care pathway design and delivery by Rosewood IRU to outreach to acute wards to enhance the care pathway for this more complex group in conjunction with Wirral and Western Cheshire CCGs using CQUIN funding. The aims were to help return people to stable community living wherever possible by using the specialist skills and extensive links with other services and providers already part of the Rosewood care pathways to create community care packages and for those requiring tertiary care and treatment to help expedite this to the best provider available for their individual needs.

What change was introduced and how was this done?
The initial phase was scoping to identify which types of individuals fell into this category and for which reasons. The team then began working with individuals to support and supplement the expertise of the inpatient and community teams and to help ensure that any needs, strengths and aspirations identified for each individual were best matched to available resources from a variety of providers including where necessary bespoke commissioned packages of care. Initial targeting was aimed at those who were on an acute ward for 40 days without a clear and timely route to discharge by that stage.

In 2012-13 the team built up to 1 OT; 2.5 nurses, 0.5 psychology assistant and backup inputs from the full Rosewood multidisciplinary team on a case by case basis. In 2013-14 with the extra remit 2 additional nursing posts were added.
The team deploys and draws upon the complex case rehabilitation and recovery skills of the Rosewood Integrated services model including care pathway delivery and review.

The service has enabled individuals to gain access to a wider range of specialist review, expertise and advice than can be efficiently funded within individual ward or community teams. The inputs are focussed and delivered when most beneficial and facilitate negotiation of aftercare packages which most individual ward and community team staff find challenging due to limited experience of this. The team also provides advice and liaison through the acute care meetings to share expertise and raise expectations of what can be realistically achieved for individuals. In doing this the service has contributed to the success of CWP acute care services in not facing the “crisis” shortage of acute beds identified in some other parts of the NHS in England and lower than average provision and occupancy of acute beds.

Challenges and how these were overcome

  1. Setting challenging but realistic expectations and goals. Careful preparation and negotiation with the key groups was essential to addressing this
  2. Working with other teams to demonstrate added value and helpful support not takeover
  3. Ensuring the model coped with staff turnover (CQUIN pump priming meant short term secondments when complex issues need long term vision and delivery)
  4. Continual review and learning- creating a culture where all views can be debated and valued whilst delivering on agreed learning and developmental outcomes
  5. Adapting the model as cases become more complex
  6. Moving the model further up and down the care pathway without losing focus

How the change can be sustained and spread
The work has been presented internally and externally including at international conferences such as the European Care Pathway Conference Glasgow 2013

What has been learned?
Complex needs can be very challenging and are individual to each person but care pathway approaches support individualisation within a consistent recovery focus framework. Variance then becomes a learning point for all concerned.

It is easy in mental health to say things are too complex but the work demonstrates that starting somewhere (in this case Rosewood IRU) and then building up and downstream from that (as in CRAC) drives up quality, drives down costs, makes services more responsive to individuals and their unique needs, strengths and aspirations.