Domain 2: Service Access, Coordination And Continuity Of Care

Question 1

Recommendation 13

Answer 1

Directories of information on VCS supports should be provided to staff working in primary care and CMHTs to ensure they are aware of and inform service users and FCS about all supports available.

Question 2

Recommendation 14

Answer 2

Where Voluntary and Community Sector organisations are providing services aligned to the outcomes in this policy, operational governance and funding models should be secure and sustainable.

Question 3

Recommendation 15

Answer 3

Social prescribing should be promoted nationally as an effective means of linking those with mental health difficulties to community-based supports and interventions.

Question 4

Recommendation 16

Answer 4

Access to a range of counselling supports and talk therapies in the community/primary care should be available on the basis of identified need so that all individuals, across the lifespan, with a mild-to-moderate mental health difficulty can receive prompt access to accessible care through their GP/Primary Care Centre.

Question 5

Recommendation 17

Answer 5

The mental health consultation/liaison model should continue to be adopted to ensure formal links between CMHTs and primary care.

Question 6

Recommendation 18

Answer 6

An implementation plan should be developed for the remaining relevant recommendations in Advancing the Shared Care Approach between Primary Care & Specialist Mental Health Services (2012) in order to improve integration of care for individuals between primary care and mental health services.

Question 7

Recommendation 19

Answer 7

The physical health needs of all users of specialist mental health services should be given particular attention by their GP. A shared care approach is essential to achieve the best outcomes.

Question 8

Recommendation 20

Answer 8

There should be further development of early intervention and assessment services in the primary care sector for children with ADHD and/or autism to include comprehensive multi-disciplinary and paediatric assessment and mental health consultation with the relevant CMHT, where necessary.

Question 9

Recommendation 21

Answer 9

Dedicated community-based Addiction Service Teams should be developed/enhanced with psychiatry input, as required, and improved access to mental health supports in the community should be provided to individuals with co-existing low-level mental health and addiction problems.

Question 10

Recommendation 22

Answer 10

The provision of appropriate environments for those presenting at emergency departments who additionally require an emergency mental health assessment should be prioritised.

Question 11

Recommendation 23

Answer 11

There should be continued investment in, and implementation of, the National Clinical Care Programme for the Assessment and Management of Patients Presenting to emergency departments following self-harm.

Question 12

Recommendation 24

Answer 12

Out-of-hours crisis cafés should be piloted and operated based on identified good practice.

Question 13

Recommendation 25

Answer 13

The multi-disciplinary CMHT as the cornerstone of service delivery in secondary care should be strengthened through the development and agreed implementation of a shared governance model.

Question 14

Recommendation 26

Answer 14

CMHTs’ outreach and liaison activities with partners in the local community should be enhanced to help create a connected network of appropriate supports for each service user and their family.

Question 15

Recommendation 27

Answer 15

An individualised recovery care plan, co-produced with service users and/or family, where appropriate, should be in place for, and accessible to, all users of specialist mental health services.

Question 16

Recommendation 28

Answer 16

All service users should have a mutually agreed key worker from the CMHT to facilitate coordination and personalisation of services in line with their co-produced recovery care plan.

Question 17

Recommendation 29

Answer 17

Further training and support should be put in place to embed a recovery ethos among mental health professionals working in the CMHT.

Question 18

Recommendation 30

Answer 18

CMHTs and sessional contacts should be located, where possible and appropriate, in a variety of suitable settings in the community, including non-health settings.

Question 19

Recommendation 31

Answer 19

The potential for digital health solutions to enhance service delivery and empower service users should be developed.

Question 20

Recommendation 32

Answer 20

The composition and skill mix of each CMHT, along with clinical and operational protocols, should take into consideration the needs and social circumstances of its sector population and the availability of staff with relevant skills.

Question 21

Recommendation 33

Answer 21

The shared governance arrangements for CMHTs as outlined in AVFC 2006–16 should be progressed, including further rollout of Team Coordinators.

Question 22

Recommendation 34

Answer 22

Referral pathways to all CMHTs should be reviewed and extended by enabling referrals from a range of other services.

Question 23

Recommendation 35

Answer 23

A comprehensive specialist mental health out-of-hours response should be provided for children and adolescents in all geographical areas.

Question 24

Recommendation 36

Answer 24

Appropriate supports should be provided for on an interim basis to service users transitioning from CAMHS to GAMHS. The age of transition should be moved from 18 to 25, and future supports should reflect this.

Question 25

Recommendation 37

Answer 25

Nationally agreed criteria should be developed to govern and resource individualised support packages for the specific needs of a small cohort of children and young people who have complex needs.

Question 26

Recommendation 38

Answer 26

In exceptional cases where child and adolescent inpatient beds are not available, adult units providing care to children and adolescents should adhere to the CAMHS inpatient Code of Governance.

Question 27

Recommendation 39

Answer 27

The HSE should consult with service users, family, staff, and those supporting priority groups to develop a standardised access pathway to timely mental health and related care.

Question 28

Recommendation 40

Answer 28

Sufficient resourcing of home-based crisis resolution teams should be provided to offer an alternative response to inpatient admission, when appropriate.

Question 29

Recommendation 41

Answer 29

A Standard Operating Guideline should be developed to ensure that sufficiently staffed day hospitals operate as effectively as possible.

Question 30

Recommendation 42

Answer 30

Individuals who require specialist Mental Health Services for Older People (MHSOP) should receive that service regardless of their past or current mental health history. People with early onset dementia should also have access to MHSOP.

Question 31

Recommendation 43

Answer 31

The age limit for MHSOP should be increased from 65 years to 70 years supported by joint care arrangements between GAMHS and MHSOP teams for individuals who require the expertise of both.

Question 32

Recommendation 44

Answer 32

GPs, mental health service prescribers and relevant stakeholders should collaborate to actively manage polypharmacy.

Question 33

Recommendation 45

Answer 33

The HSE should collate data on the number and profile of delayed discharges in acute mental health inpatient units and develop appropriately funded responses.

Question 34

Recommendation 46

Answer 34

An Expert Group should be set up to examine Acute Inpatient bed provision and to make recommendations on capacity reflective of emerging models of care, existing bed resources, and future demographic changes.

Question 35

Recommendation 47

Answer 35

Sufficient Psychiatric Intensive Care Units (PICUs) should be developed with appropriate referral and discharge protocols.

Question 36

Recommendation 48

Answer 36

A cross-disability and mental health group should be convened to develop national competence in the commissioning, design and provision of intensive supports for people with complex mental health difficulties and intellectual disabilities.

Question 37

Recommendation 49

Answer 37

Intensive Recovery Support (IRS) teams should be provided on a national basis to support people with complex mental health needs in order to avoid inappropriate, restrictive and non-recovery-oriented settings.

Question 38

Recommendation 50

Answer 38

The development of a national network of MHID teams and acute treatment beds for people of all ages with an intellectual disability should be prioritised.

Question 39

Recommendation 51

Answer 39

Speech and Language Therapists (SLT) should be core members of the Adult-ID and CAMHS-ID teams.

Question 40

Recommendation 52

Answer 40

Investment in the implementation of the Model of Care for Early Intervention Psychosis (EIP), informed by an evaluation of the EIP demonstration sites, should be continued.

Question 41

Recommendation 53

Answer 41

The National Mental Health Clinical Programmes for Eating Disorders, Adults with ADHD and the Model of Care for Specialist Perinatal Mental Health Services should continue to have phased implementation and evaluation.

Question 42

Recommendation 54

Answer 42

Every person with mental health difficulties coming into contact with the forensic system should have access to comprehensive stepped (or tiered) mental health support that is recovery-oriented and based on integrated co-produced recovery care plans supported by advocacy services as required.

Question 43

Recommendation 55

Answer 43

There should be ongoing resourcing of and support for diversion schemes where individuals with mental health difficulties are diverted from the criminal justice system at the earliest possible stage.

Question 44

Recommendation 56

Answer 44

The development of further Intensive Care Rehabilitation Units (ICRUs) should be prioritised following successful evaluation of operation of the new ICRU on the Portrane Campus.

Question 45

Recommendation 57

Answer 45

A tiered model of integrated service provision for individuals with a dual diagnosis should be developed to ensure that pathways to care are clear. Similarly, tiered models of support should be available to people with a dual diagnosis of intellectual disability and a mental health difficulty.

Question 46

Recommendation 58

Answer 46

In order to address service gaps and access issues, a stepped model of integrated support that provides mental health promotion, prevention and primary intervention supports should be available for people experiencing homelessness.

Question 47

Recommendation 59

Answer 47

Assertive outreach teams should be expanded so that specialist mental healthcare is accessible to people experiencing homelessness.

Question 48

Recommendation 60

Answer 48

Continued expansion of Liaison Mental Health Services for all age groups should take place in the context of an integrated Liaison Mental Health Model of Care.

Question 49

Recommendation 61

Answer 49

The HSE should maximise the delivery of diverse and culturally competent mental health supports throughout all services.

Question 50

Recommendation 62

Answer 50

Building on service improvements already in place, individuals who are deaf should have access to the full suite of mental health services available to the wider population.

Question 51

Recommendation 63

Answer 51

Persons in Direct Provision services and refugees arriving under the Irish refugee protection programme should have access to appropriate tiered mental health services through primary care and specialist mental health services.

Question 52

Recommendation 64

Answer 52

Appropriately qualified interpreters should be made available within the mental health service and operate at no cost to the service user.

Question 53

Recommendation 65

Answer 53

The HSE should ensure access to appropriate advocacy supports in all mental health services.