Key workers and care programmes

The allocation of a team member as key worker (or case manager) for each patient being assessed is the usual method of work in teams of this sort. Which member becomes key worker for which patient depends upon the ability of the team to match the needs of each patient with the skills available amongst the team members, according to their training. Although all patients are discussed in detail at team meetings, and any team member can contribute suggestions and viewpoints, it is usually accepted that once a care programme of activities is identified and agreed upon, most if not all of the contacts with the patient and family will be made by the key worker. The key worker also has the responsibility of reporting back to the team about progress, and about problems encountered which might require new major decisions or changes in the care programme.

The terms 'case manager' and 'care programme' have been used above to refer to individual mental health professionals in direct contact with the patient, but these simple meanings must not be confused with care management, a more recently introduced concept that refers to a model of 'extended brokerage case management' recommended by, for instance, the United Kingdom Department of Health(38,39> in which care managers are not directly involved in direct service delivery. These terms are unfortunately sometimes used synonymously, and further confusion is sometimes caused by the terms and models of the Care Programme Approach, also of the United Kingdom Department of Health,(49 and the more positively evaluated Programme for Assertive Community Treatment/4!ยป Reviews by Burns(42> and others'41.) are very helpful guides through the complexities of this topic.

In addition to the specific medical responsibilities noted above, psychiatrists as members of a multidisciplinary team have other important areas of expertise that should be recognized by the other members. Experienced psychiatrists are likely to have special skills in the assessment of dangerousness and risks of various sorts, and psychiatrists at any stage in their training should be able to show by helpful examples that they are specially trained to summarize information. Even more important is their ability to produce an overall formulation that is the key to arriving at a care programme.

For a team to be to be successful, its members have to share openly stated common goals and policies, and need to develop an indefinable but vital 'team spirit' by which they are helped both to depend upon and to support each other, even though they have marked differences in training, status, and remuneration. To be an efficient and accepted long-term member of a multidisciplinary team of this type requires personal characteristics not necessarily possessed by all mental health professionals. Tolerance of the different viewpoints of other team members is essential, in addition to the professional skills needed to carry out the work required.

The frequency of team meetings is determined by the size and nature of the workload. Special meetings to discuss topics not directly related to the patients are also usually found to be necessary, so as to deal with issues such as team policies, recruitment and appointments, relationships with outside agencies (for instance about too few, too many, or inappropriate referrals), interpersonal problems between team members, and work-related stress in the team members. This last problem is particularly important in teams dealing with crisis intervention and psychiatric emergencies because of the need to maintain a rapid turnover of patients and families who are seen over only a limited period of time.

A different type of problem that may need sensitive handling by the team leader and others in authority outside the team itself is the relationship between the team members and their immediate superiors (or 'line managers') in the hierarchy of their own discipline. Each team member has to strike a balance between personal needs for professional supervision and training, and the ability to make decisions within the team because of special skills not possessed by other team members. This type of problem will be minimized if team members are comparatively senior and experienced within their parent discipline. Student health workers are not appropriate as team members, but they can benefit greatly if attached to the team as observers. They will have the opportunity to learn something about how other disciplines operate, which is an aspect of training usually absent from the rest of their training.

Disagreements often arise within a team about the best time for patients to be discharged from care, or about the precise time for referral when it is in the patient's interests to be assessed by another service. In countries where outpatient services and inpatient services are staffed by different teams under different organizations, there will be many such breaks in care, and multidisciplinary teamwork can become frustrating. But where continuity of care between different parts of the general psychiatric services is the norm, the most frequent changes of care result from the need for the patient to be assessed for more specialized treatment such as rehabilitation, cognitive- behavioural therapy, or intensive psychotherapy. The team needs to develop agreed policies for these occasions, and these will depend largely upon the structure of the local services available.

Although no systematic information is available, there is little doubt that the style of multidisciplinary teamwork just described is spreading through the mental health services in many countries. Its popularity and success are probably due to the increased job satisfaction experienced by the non-medical team members, in addition to the recognition of multiple rather than single needs in a large proportion of psychiatric patients and families already noted. Multidisciplinary styles of working are especially important in emergency psychiatric services and crisis intervention units. (4 44>

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