Community Mental Health Outreach | Providence Centered Care

What it is

The gap between a discharge letter and an actual life

People come out of hospital, or off a caseload, or through a crisis, and the clinical support ends while the practical problems do not. The rent is behind. There are eleven unopened letters. Nobody has eaten properly in a fortnight. The appointment that would fix half of it is on Tuesday and getting there feels impossible.

Outreach is support aimed squarely at that gap. It is not therapy and it is not a clinical service. Diagnosis, medication and treatment belong to the community mental health team, the GP and the psychiatrist. What we do is the practical and the human side that determines whether the clinical work has anything to hold onto.

The work is unglamorous. Going with somebody to an appointment they would otherwise miss. Sitting down with the letters. Ringing the housing officer together rather than for them. Getting shopping in. Establishing that somebody gets out of the house once a day. Making sure a person who has stopped answering the phone is actually alright.

The single most important ingredient is consistency. Someone who has been passed between eleven services in two years does not open the door to a new name. The same worker, turning up when they said they would, over months, is what makes any of the rest possible.

This is a support service, not a clinical one. Diagnosis, medication and treatment stay with the mental health team and the GP, and we work alongside them.

This is likely right if

Someone has been discharged from hospital or a mental health team and is struggling to manage
Appointments are being missed and the reasons are practical as much as anything
A tenancy is at risk because everyday things have stopped being managed
Someone is isolated and has withdrawn from most contact
A pattern of crisis and readmission needs breaking

Something else may fit better if

Someone is in crisis right now, where the crisis team, GP or emergency services are the call
What is needed is therapy or psychiatric treatment rather than practical support

In practice

What outreach looks like week to week

Regular contact and practical work, at whatever pace the person can actually manage.

Turning up

The same worker, at a time that was agreed, reliably. For somebody who has been let down repeatedly this is the whole intervention for the first few weeks.

The letters

Sitting down with the post together. Benefits, housing, debt, appointments. Opening them with somebody present is far easier than opening them alone.

Getting to appointments

Reminders, and going along where that is what makes the difference. A missed appointment often means going back to the bottom of a waiting list.

Keeping the tenancy

Rent, arrears, repairs, neighbours, the housing officer. Losing a tenancy undoes years of progress and it usually starts small.

Everyday things

Shopping, meals, laundry, getting out of the house. Structure is not a small thing when everything else has come apart.

Noticing early

A worker who sees somebody weekly notices withdrawal before it becomes a readmission, and tells the mental health team while there is still time to act.

The detail

What is included, and what is not

Set out plainly so there is nothing to discover later. Anything not listed here can still be discussed, and often arranged.

Included as standard

A named worker with planned, regular contact
A support plan written with the person rather than about them
Support with benefits, housing, appointments and correspondence
Accompaniment to appointments where that is what makes them happen
Joint working with the community mental health team, GP and housing
Escalation to the clinical team when things start to slip

Arranged separately

Therapy, counselling and psychological treatment
Prescribing, medication reviews and psychiatric assessment
Crisis response, which is the crisis team or emergency services

Getting started

From first call to first visit

Referrals come mostly from mental health teams, social workers and housing, but we take them from families and individuals too.

01

Referral

From a community mental health team, social worker, housing officer, GP, family member, or the person themselves.

02

Meeting the person

On their terms, somewhere they are comfortable. The first meeting is about whether they want this at all, because support nobody agreed to does not work.

03

Agreeing what matters

Their priorities, not a template. If the thing that matters most is the arrears rather than the appointments, we start with the arrears.

04

Regular contact and review

A rhythm the person can rely on, reviewed as things change, and stepped down deliberately rather than stopped abruptly.

Cost

How this is paid for

Outreach is usually commissioned by a local authority or an NHS mental health service. It can also be arranged through a Direct Payment or a Personal Health Budget, which give the person a say in who supports them.

Where somebody has been detained under the Mental Health Act and is eligible for section 117 aftercare, support can be funded jointly by the NHS and the local authority at no cost to the person. This is an entitlement rather than a discretionary service and it is worth asking about directly.

Read the full guide to funding

Questions

What families ask us about this

Is this therapy?

No. Therapy and psychiatric treatment come from the mental health team and the GP. We provide the practical and social support around them, which is often the thing that determines whether the clinical work can land at all.

Will it be the same worker?

Yes, as far as we can possibly manage it. Consistency is not a nicety in this service, it is the mechanism. Trust with somebody who has been passed around for years is built by one person turning up repeatedly.

What if the person does not want support?

Then we do not force it. We would rather spend six weeks building a relationship at the door than write a plan that gets refused. Support somebody has not agreed to does not work and often makes the next attempt harder.

What is section 117 aftercare?

If somebody has been detained under certain sections of the Mental Health Act, the NHS and the local authority have a duty to provide aftercare free of charge. A lot of people entitled to it are never told. If this might apply, ask the mental health team directly.

Do you support people with a dual diagnosis?

Yes. Mental health difficulties alongside substance use is something we work with specifically rather than treat as a reason to decline. It has its own page.

What happens in a crisis?

Crisis response is the crisis team, the GP or emergency services, and we will help somebody reach them. What outreach does is reduce how often the crisis point is reached in the first place.

Also worth reading

Services that often go together

Dual Diagnosis and Substance Misuse

Support for people living with a mental health condition and substance use together, without being passed between two services that each want the other to go first.

Refer somebody, or ask about someone

We take referrals from mental health teams, social workers, housing, families and individuals. You do not need a professional to refer you.

Make a referral Talk to someone first

Emergency placements are answered 24 hours a day, seven days a week.