Strengthening our intensive and assertive community care
This extra support for our existing Intensive and Assertive Care service includes additional Recovery Support Workers working alongside multidisciplinary teams. It is designed for people on our psychosis pathway whose families may have raised concerns, and who may be at risk of relapse, deterioration or serious harm.
Around 200 service users are currently on this pathway. Many have multiple and complex social needs, including housing difficulties, financial problems, self-neglect, or co-occurring drug and alcohol use. Some may also have had negative, harmful or traumatic experiences with statutory services, including mental health services or the criminal justice system.
Service users now have access to Recovery Support Workers in each borough’s Integrated Recovery Hub, including eight additional recruits. They work closely with Enhanced Response Practitioners, care co-ordinators, families and partner agencies.
Care can be stepped up or down depending on each person’s needs, with Integrated Recovery Hub care co-ordinators staying involved throughout to provide consistency. Importantly, no one will be discharged simply because they are finding it difficult to engage.
By strengthening Intensive and Assertive Care, we aim to provide more collaborative, responsive and robust support for service users, helping them stay safe and receive the care they need in the community.
This work follows the tragic events in Nottingham in 2023. National reviews were carried out by the Care Quality Commission and NHS England, and the Trust committed to a series of actions in response, including improving support for people whose needs may be harder to meet through standard approaches.
The Community Service Line has worked with clinicians and people with lived experience to shape the strengthened model.
Dr Uju Ugochukwu, Clinical Director for the Community Service Line, said:
“If a service user’s mental health is deteriorating, our whole multidisciplinary team will respond together to provide intensive support in the community to prevent relapse and hospitalisation, alongside a dedicated Recovery Support Worker and local Enhanced Response Practitioner. Engaging with families and carers will be a crucial part of this.
“This is a vital step in strengthening our response to people in the community who need our help most, so they can stay safe and focused on recovery rather than being admitted to hospital.”
The outcomes we are working towards include reducing health inequalities, Mental Health Act detentions, crisis presentations and demand for inpatient beds. We also aim to improve engagement with services, adherence to treatment, recovery outcomes, and the experience of service users, families and carers.
