Personality Disorder Case Management Team
This team of four nurses provides intensive case management, based on the psychological model of Structured Clinical Management (SCM) when clinically possible, to those service users with personality disorder who present with the most complexity and who use local resources most intensively. This has allowed most of those service users, formerly out of area, to be repatriated and has also prevented other service users going out of area.
Each case manager has a reduced caseload of 10 service users and offers 100 weeks of intensive case management to each service user in their care. The team provides care co-ordination taking responsibility for care programme approach (CPA), with regular reviews with the community psychiatrist (Responsible Clinician) in the original CMHT. At the end of 100 weeks of care, service users will either be discharged from services or referred back to their original CMHT (most hopefully to be maintained at a non-CPA level). At the point of discharge, service users will continue to have access to the personality disorder day and crisis service for ongoing support.
The team works to its clinical capacity, taking on new referrals when spaces are available. When requests are made but no spaces are available, the personality disorder hub offers support to CMHTs by offering consultations to staff in other teams, to support their ongoing work with service users. Additionally the PD case managers offer a monthly practitioner support group for practitioners from other CMHTs to support with their work (this includes writing extended care plans).