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Recovery & Rehabilitation Team

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Recovery & Rehabilitation team deliver Assertive Community Treatment to patients suffering with a severe mental illness, who require intensive treatment and interventions.

Flexible Assertive Community Treatment is a whole systems approach to recovery from mental illness that maximises an individual's quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and leads to successful community living through appropriate support.

  • Service Objectives

    • The service consists of Psychiatrists, Psychologist, Social Workers, Occupational Therapist, Mental Health Nurses and Support Workers.  Here the service aims to,
      • Work collaboratively with service users and their carer within a framework of the Care Programme Approach
      • Offer time unlimited treatment and interventions
      • Work within a multi-disciplinary specialist service providing treatments for people experiencing severe and enduring mental health problems
      • Reduce the frequency of hospital admissions and length of stay; reduce/minimise symptoms of mental illness and increase independence and social inclusion
      • Following the recovery and social inclusion model of care, to support patients to access education, employment, housing, benefits and community based social activities
      • Increase daily living skills
      • Increase coping strategies
      • Provide relevant information to service users and their carers including psycho-education and signposting to other services
      • Provide carers assessment where necessary
      • Provide support and integrated care planning during in-patient admissions (Crevichon Ward/Off-island placements)
  • Referral

    • Recovery & Rehabilitation Team service will almost always be through the Adult Mental Health Service.  All referrals are discussed and accepted for assessment via the weekly Intake Meeting.
    • The minimal information which is required to accompany any referral includes:
      • An internal referral form
      • An up to date service user history
      • Current comprehensive assessment (inclusive of contextual risk)
      • Current care and treatment plans
      • An overview of the referrers intended outcomes
      • An indication that the service user is aware of and agrees to the referral
  • Assessment

    • Once referral has been agreed an assessment will be arranged within 72 hours.  The assessment will be face to face and will take place with a Nurse and/or Occupational Therapists, (to include discussion with family/carers if appropriate).  This may be a joint assessment with referrer if appropriate.
  • Intervention

    • Following a period of assessment a range of treatment options/interventions may be offered.  The care provided will be tailed to an individual's needs, and will be regularly reviewed and evaluated.  The team will aim to facilitate early discharge of their service users who will at times require admission by developing a package of intensive community monitoring of mental state and risk.  Below is a list of interventions that the service use,
      • Medication management and home treatment
      • Mental state assessment and review
      • Anxiety management
      • Decider skills
      • Substance misuse
      • Self-care support
      • Financial support
      • Psychological assessment and therapy
      • Occupational assessment and therapy
  • The Oberlands Clinic

    • Patients who are routinely prescribed depot medication by their consultant psychiatrist or who require regular blood tests related to their medication can attend the clinic rather than go to their GP.  It will in future also offer physical health monitoring for the patients who have a severe mental illness.  The clinic will have links with other services such as the dietetics department, smoking cessation service, chest and heart clinic, diabetes nurses etc. Once patients have had a full annual physical health check they will be invited back for regular monitoring of any conditions, offered advice and support and will be referred to other services as appropriate.

For any further information you can contact The Oberlands Centre on 01481 725241 ext: 3561.

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