COVID-19: Community mental health settings

Page last updated: 21 April 2020

Explore our guidance for psychiatrists and their colleagues working in community mental health settings. Is something you want to know not covered here? Help us keep our guidance comprehensive by submitting a question.

Clinicians and other health professionals might need to work together to create clear and concise clinical decision tools to enable the allocation of care and treatment for community mental health patients/patients based on need. This framework might be useful when developing these.

Define patient groups by hierarchy of need

  • Identify those who are in high-need groups based on the following criteria:
    • Risk
    • Mental health acuity
    • Physical health acuity
    • Accommodation/ home environment
    • Support network (care package, carers, third sector services, community resources)
    • Other concerns/vulnerabilities (substance use, chaotic lifestyles).
  • Consider need by diagnosis:
    • Psychotic illness, including puerperal psychosis (particularly those who may be adversely affected by incorporating the COVID-19 situation into their delusional beliefs)
    • Intellectual disability and those lacking capacity
    • Anorexia (who may also need enhanced support with physical health monitoring)
    • Anxiety disorders and substance misuse disorders (who may suffer from withdrawal symptoms during periods of self-isolation)
    • Cognitive impairment.
  • Consider the impact of medication: patients on high risk medications, including:
    • lithium
    • clozapine
    • valproate
    • antipsychotics
    • high dose antipsychotic therapies (HDAT).
  • Consider the potential susceptibility to the virus for certain groups of patients, such as:
    • older adults, particularly those over 70 years
    • people with severe and enduring mental illnesses who smoke, use alcohol and are in poorer physical health.
    • people with existing respiratory disease e.g. COPD and asthma, and people at risk of chest infections.
    • people who are also immunocompromised e.g. HIV positive/ undergoing chemotherapy
    • people who are malnourished for any reason (including anorexia nervosa and metabolic disorders) often have a reduced immune response and it may contribute to poor outcomes
    • people with substance use disorders
    • people with an underlying mental illness that means they do not adhere to self-isolation advice, such as delusional beliefs, chaotic lifestyles etc
  • PHE Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19 sets out that the following people should be deemed "extremely vulnerable"  and sets out how they should be treated:
    • Solid organ transplant recipients
    • People with specific cancers:
      • people with cancer who are undergoing active chemotherapy
      • people with lung cancer who are undergoing radical radiotherapy
    • people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
    • people having immunotherapy or other continuing antibody treatments for cancer
    • people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
    • people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
  • People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD.
  • People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell).
  • People on immunosuppression therapies sufficient to significantly increase risk of infection.
  • Women who are pregnant with significant heart disease, congenital or acquired.

 

  • Complete RAG rating assessment/ zoning.
  • Review caseload at least weekly for community mental health teams and daily for home treatment teams.
  • Consider whether there are local clinical or ethics advisory groups in place to provide advice on local policy and practice if helpful.
Risk rating Characteristics
Red

Vulnerable, high risk.

Frequent and preferably face to face contact [even if via window], or telephone/ online consultation if units are refusing visits.

Include – Assertive Outreach Team, FACT, LAI and clozapine clinic

Amber

Moderate risks/ concerns.

Require regular monitoring and review – via telephone with option to step up to face to face if required

Green

Generally stable presentation

Require telephone contact - need telephone review in place of face to face

Option to escalate

Managing care pathways with limited staffing resources

Consideration should be given to how to sustain continuity of treatment for different patients caused by unpredictability of staff absence and/or patient and staff self-isolation.

  • Local solutions are likely to be best for managing care pathways, because of the unpredictability of staff absence or patient and staff self-isolation.
  • Priority for delivery should be interventions that prevent crises as this is likely to have a significant impact upon demand for acute services.
  • Plans should be made to ensure medication treatment continues, which will require monitoring of mental and physical health, depot scheduling and supervised administration or oral medication.
  • Consideration should be given to whether a face to face interaction is needed or whether contact can be safely managed over the phone or via other visual technologies as per RAG rating. Services should progress the option for undertaking some assessments via indirect methods, such as tabletop reviews, review of video footage, telephone/telecons, Skype etc to limit direct face to face contact/observations.
  • Local areas should agree and follow guidance for how best to assess mental state on the telephone. Consideration must be given to older people, or anyone who might be less likely to have access to technology or be able to hear well over the phone.
  • To sustain continuity of treatment for different patients and reduce demands on staff, clinicians should consider the resource implications when changing current treatment or care plans and take a calculated risk. Examples of decisions to delay, slowed or changes to reduce demands on staff include:
    • postponing new patient appointments for a memory assessment
    • patients requiring medication could stay on a lower dose and delay titration until staff can effectively monitor physical health to ensure it’s safe to change the dose provided this is clinically appropriate
    • patients deemed low risk in IAPT services could have treatment plans suspended or changed to telephone or Skype if clinically appropriate.
  • Community mental health teams must determine how best to maintain contact in order to support ongoing assessment of these patient groups.

Keeping patients and families informed

  • Healthcare professionals should consider how best to update patients and families about what might be changing during the pandemic via regular contact.
  • Try to ensure provision of easy read/video/alternative media to convey information. Consider a central hub of easy read material themed into relevant areas.
  • Services/personnel should consider practical instructions on what to do in relation to COVID-19 i.e. people with dementia who may not know what a distance of 2 metres is for social distancing, for example.

This section of the guidance is in line with NHS England's guidance for managing capacity and demand within inpatient and community mental health, learning disabilities and autism services for all ages (published on 25 March).

Maximising capacity

NHS England have stated it will be necessary to consider the following when developing capacity plans:

  • Ongoing risk stratification and dynamic risk registers
  • Flexible approaches to deployment of workforce across different settings, e.g. mental health practitioners from community services moving into crisis teams, ensuring liaison psychiatry teams have capacity to support discharge, working with voluntary sector providers and using technology to provide remote professional access
  • Refresher training and upskilling staff on key aspects of physical healthcare
  • Standing down activity not directly related to care provision after risk assessment of the impact on safety, business continuity and the wider system, such as: non-essential education and training; audit activities; quality improvement initiatives; and reporting on targets where clinical input is required
  • Waiting times for routine and non-urgent care may be impacted. Patient and clinical safety should be prioritised.

NHS England have suggested that services consider using the CREST appointment/bed modelling tool to support capacity planning.

To both maximise the use of community insight and to draw on the insight and expertise of partners, response plans will need to be developed alongside patients, families, carers, voluntary community sector (VCS) organisations as well as neighbouring mental health, learning disability and autism providers. This will include planning within an NHS-led provider collaborative, with social care partners, criminal justice system, commissioners and education providers for children and young people.

Community service planning (including IAPT)

  • Forthcoming NHSE guidance on patient engagement and digital IAPT delivery will support communications and care planning.
  • Important to maintain up-to-date risk stratification to prioritise service delivery. In learning disability and autism services, use of the dynamic support register, risk of admission register and regular review between local agencies will be vital to prioritise resources.
  • CMHTs/CYPMHS and community learning disability teams may want to move to daily huddles to prioritise who is most at risk of becoming mentally unwell and then use team resources to prioritise contact, in partnership with VCS where appropriate.
  • NHSE offer a number of options to help release and create priority community support capacity, including: temporarily pooling services that are currently stand-alone; releasing appropriately skilled staff from corporate functions to enhance clinical capacity; and partnerships with VCS.
  • The guidance emphasises that services such as IAPT should not simply close to new patients at this time. IAPT services can consider the digital options available to continue to deliver care.

Public Health England has published ‘COVID19: guidance for home care provision’.

  • All staff members to explain to the patient/carer the reasons for temporary change in protocol for carrying out telephone screening prior to home visits and that when staff do visit, they may be wearing PPE.
  • All staff to ensure they understand local arrangements for the supply of staff PPE equipment if required for particular community visits.

Prior to a home visit:

  • The staff member to make a telephone contact to the patient/carer to establish the physical health status of the patient/carer(s);
  • The staff member to ask the patient/carer:
    • Do you have a high temperature/fever?
    • Do you have a new continuous cough?
    • Does anyone at your home address have these symptoms?
  • If the answer is yes to any of above this will be regarded as “symptomatic” for the purposes of this protocol.
  • Elicit when symptoms started/are they new symptoms? (Consider SUpatients physical health history/baseline/Public Health England advice re have they recently returned from high risk countries, have they had any contact with someone with suspected or confirmed Covid-19).
  • Have they sought any medical attention/111/GP?
  • If SUpatient/carer advises they are symptomatic carry out risk assessment as to whether the visit is essential for maintaining the SUpatient  mental and physical wellbeing i.e those patients in crisis/requiring medication;
  • If the SUpatinet/carer is symptomatic, give advice (follow link for current stay at home guidance).
  • If in the case of a medical emergency where the patient is symptomatic for Covid 19 – call 999. Inform them that the patient is symptomatic for COVID19.
  • If visit is not essential – further to your risk assessment described above - do not visit.
  • Report to manager/RMO.  Monitor with telephone contacts while care plan is established under COVID 19 advice. Update care plan confirming arrangements for maintaining contact and safe care.
  • If the SUpatient/carer reports mild symptoms and a home visit is considered absolutely essential for safe delivery of care, arrangements to be made for staff to visit using PPE equipment.  See section on the community below for advice on the use of PPE equipment in this setting.
  • If unable to make successful telephone contact prior to visit, try alternative methods of contact e.g. phone carer. If contact cannot be established and visit is not essential, do not visit, but continue to try to make contact. If home visit is absolutely essential, to carry out home visit as planned and complete doorstep assessment.

Role of Doorstep Assessment

  • If a doorstep assessment is deemed appropriate and after being undertaken there is a concern that the patient/carer has symptoms do not enter the home.  Advice should be given to the patient. Carry out supportive contact remotely. E.g. telephone from car.

This section of the guidance is in line with the interim national guidance already available for primary care services, which offers four main principles: 

  • identify potential cases as soon as possible
  • prevent potential transmission of infection to other patients and staff
  • avoid direct physical contact, including physical examination, and exposures to respiratory secretions
  • isolate the patient, obtain specialist advice and determine if the patient is at risk of COVID-19

Managing suspected COVID-19 cases during a consultation 

If COVID-19 is considered possible when an IAPT session or outpatient consultation is already in progress, withdraw from the room, close the door and wash your hands thoroughly with soap and water. Avoid physical examination of a suspected case.

The patient, any accompanying family, belongings and any waste should remain in the room with the door closed. Advise others not to enter the room. If a clinical history still needs to be obtained or completed, do this by telephone. The patient should be asked to call NHS 111 from the room. 

If entry to the room or contact with the patient is unavoidable in an emergency, wear personal protective equipment (PPE) in line with standard infection control precautions, such as gloves, apron and fluid resistant surgical mask (FRSM) and keep exposure to a minimum. All PPE in full should be disposed of as clinical waste. 

When a telephone interview is being conducted with a patient located elsewhere (for example at home) and it is determined that COVID-19 is possible (based on the PHE criteria for a possible case), a face-to-face assessment in primary care (including out-of-hours centres and GP hubs) must be avoided.

Instead, call the local secondary care infection specialist to discuss safe assessment, if hospital care is being considered, if not refer to NHS 111. 

This section of Public Health England guidance (updated as of 19 March 2020) includes registered residential care and nursing homes for people with learning disabilities, mental health and/or other disabilities. 

If a resident has symptoms of COVID-19 in a residential care home, key points include: 

  • Implement isolation precautions in the same way they would if an individual had influenza. If isolation is needed, a resident’s own room can be used. Ideally the room should be a single bedroom with en-suite facilities. 

  • Much of the care delivered in care homes will require close personal contact. Where a resident is showing symptoms of COVID-19, steps should be taken to minimise the risk of transmission through safe working procedures. Staff should use personal protective equipment (PPE) for activities that bring them into close personal contact, such as washing and bathing, personal hygiene and contact with bodily fluids. Aprons, gloves and fluid repellent surgical masks should be used in these situations. If there is a risk of splashing, then eye protection will minimise risk. 

  • If neither the care worker nor the individual receiving care and support is symptomatic, then no PPE is required above and beyond normal good hygiene practices. General interventions may include increased cleaning activity to reduce the risk of the virus being present on hard surfaces, and keeping property properly ventilated by opening windows whenever safe and appropriate. 

Other guidance for care homes on keeping people safe includes: 

  • Use tools to report capacity for bed vacancies (such as Capacity Tracker or Care Pulse) to support system resilience. 

  • Use tools for the secure information transfer, such as NHSMail where accessible. 

  • Increase the use of Skype and other tools for secure virtual conference calls, to ensure advice from GPs, acute care staff, and community health staff can be given. 

You are likely to be asked by your Trust to consider which teams need to extend operational hours and explore options for alternative care models, including telecare and ‘hub and spoke’ models. 

The guidance also sets out steps that the NHS and local authorities can take to support care homes. Clinicians will need to support this work. 

Supported living providers 

As well as the Public Health England guidance for supported living (updated on 19 March 2020), there is further guidance from PHE for individuals, families and informal care workers about how to maintain home care safely if they are advised to isolate at home (updated on 20 March 2020).  

Most of the care and support provided within supported living environments cannot be deferred to another day without putting individuals at risk of harm. It is therefore vital that these services are prioritised. 

  • Providers are advised to do the following:
  • Review client list and level of informal support available to individuals. 
  • Work with local authorities to identify those who fund their own care and help to determine informal support available. 
  • Map all local authority-commissioned care and support plans. 
  • Work with local authorities to establish mutual aid plans for sharing workforce across supported living, home care and health service providers. 

Note the arrangements being put in place by NHS111, CCGs and local authorities to refer vulnerable people self-isolating at home to volunteers for practical and emotional support. 

If someone in supported living has symptoms of COVID-19, risks to their health and wellbeing must be assessed and appropriate action taken. If neither the individual in supported living nor care worker is symptomatic, no personal protective equipment is required above and beyond normal good hygiene practices. 

General interventions may include increased cleaning activity to reduce risk of virus retention on hard surfaces and keeping property properly ventilated by opening windows whenever safe and appropriate. 

Hostel or day centre providers for people experiencing rough sleeping

Guidance for hostel or day centre providers of services for people experiencing rough sleeping:

  • hostels and day centres do not need to close at the current time, unless directed to do so by Public Health England or the government 
  • frequently clean and disinfect regularly touched objects and surfaces using your standard cleaning products 
  • if a member of staff becomes unwell on site with a new, continuous cough or a high temperature, they should be sent home 
  • if a resident in a hostel becomes unwell, they should stay in their room 
  • if someone becomes unwell in a day centre, and they do not have a home or room in which to self-isolate, they should be isolated temporarily in an area of the day centre and staff are advised to contact the local authority 
  • staff, residents and visitors should be reminded to wash their hands for 20 seconds, more frequently and catch coughs and sneezes in tissues 
  • local authority public health, housing and social care teams are encouraged to work closely together to identify appropriate local solutions for people who don’t have anywhere to self-isolate. The Ministry for Housing, Communities and Local Government (MHCLG) intends to issue a further communication to local authorities on this in due course 

Members of staff need to consider contingency plans for situations such as: 

  • reduced or interrupted supply of medicines, or access to them 
  • reduced access to or interrupted supply of drugs or alcohol 
  • greater vulnerability to the effects of viral infection because of reduced immunity from poor health, drug and alcohol use, or medication for other conditions 
  • risk of exacerbation of breathing impairment from coronavirus (COVID-19) due to simultaneous substance misuse e.g. opioids.

Responses should include ensuring that sufficient treatment capacity is available if people look for withdrawal support or substitute prescribing as an alternative to using illicit drugs, ie opioid substitution therapy. 

This guidance on clinical management of drug misuse and dependence can be used when considering these contingency plans. 

While specific guidance relating to COVID-19 is being developed, much of what has already been on the NHS worker guidance on COVID-19 will apply to working in mental health settings. 

This includes information on assessment and diagnosis and management of suspected and confirmed cases. 

NHS England and NHS Improvement have written to all mental health trust chief executives and mental health leads across clinical commissioning groups and sustainability and transformation partnerships to confirm a request that all areas should have established an open access 24/7 urgent NHS mental health telephone support, advice and triage service by 10 April. This is almost one year ahead of the original schedule in the NHS Long Term Plan of March 2021.

Children and young people and their parents/carers should have access to the service, either through all ages option or as a dedicated access point. Trusts have also been asked to confirm the following is in place by 10 April:

  • Ensure: 24/7 open access crisis line telephone numbers and contact details are publicly available online (including a specific CYP number if necessary); accessibility for people with intellectual disability and/or autism has been considered; and contact details for other support such as IAPT and voluntary sector helplines are provided.
  • Ensure: trust's website and literature no longer direct people to A&E, 999 or NHS111 as the default (unless it is part of a properly resourced and planned urgent mental health pathway within or via NHS111); information is provided online about when A&E/999 is appropriate; 
  • In areas where these services are established, consideration has been made to any additional capacity that might be required and redeployed not only for the telephone service but also to services that can provide all-ages follow-up care.

An annex to the letter also offers a set of further considerations in establishing the 24/7 services, with points including:

Key service principles

  • There should be no restrictions on who can refer and mental health crisis should be self-defined.
  • While it is expected that a substantial proportion of care needs will be met through telephone or video consultations, provision for urgent face-to-face assessments must also be in place. 
  • Ensuring an age-appropriate response - professionals with competency in meeting needs of CYP or older adults should ideally be responding to presentations from those groups. Trust websites should clearly display where there are separate teams/services for different age groups.
  • Ensuring equity in access - while open access urgent services may not be able to provide specialist support across a range of needs, they must not reject calls from people with mental health needs because they have other conditions, e.g. intellectual disability, autism, dementia, substance misuse problems.

Potential options for increasing capacity

  • Redeploy staff from other services with reduced activity or deemed less essential during COVID-19 period
  • Ask qualified staff who are well but self-isolating to conduct telephone and video support
  • Consider establishing a combined CYP and adult service support offer to cover 24/7 where bespoke CYP services are in place but yet to be operating at 24/7
  • Work with voluntary and community sector services to provide a complementary and integrated helpline offer.

Funding

  • All areas have resources confirmed for these services through transformation funding
  • NHSE/I are clear that 'Financial constraints must not and will not stand in the way of taking immediate and necessary action.'

NHS.UK website - crisis service postcode finder

  • A national service finder for urgent mental health support will be compiled by NHSE/I and NHS Digital from all trust websites and made available through a postcode search on the NHS.UK website.

During the Coronavirus outbreak, many services are under stress. Work in some psychological therapies services has been temporarily suspended, and staff redeployed to cover absent colleagues. Face to face meetings with trainees have ceased in many places, at the very time that support and space to think is at a premium.

We appreciate the enormous challenges clinicians are facing as they grapple with the threat from COVID-19 and the great work being done to adapt and support your teams, colleagues and trainees.

The Faculty of Medical Psychotherapy has compiled the following guidance for members:

  1. Psychotherapeutic services should not prematurely stop seeing patients. There may be local pressures which make continuing services remotely impossible, and psychotherapy services may be viewed as less essential than other mental health services, but the needs of the patients in treatment should always be weighed against needs elsewhere.
  2. As psychiatrists, medical psychotherapists should be willing to take on additional tasks within their competence as required by the local situation, whilst not neglecting their core service.
  3. The way that patients are assessed and treated, and staff support/supervision is delivered, may need to change, but in many cases these activities can continue with appropriate adjustments.
  4. Clinicians should consider carefully whether the aims of treatment can be delivered remotely, such as by phone or Teams, and in some cases psychotherapy will need to be more supportive and less challenging when carried out remotely rather than in person.
  5. Case discussion (Balint) groups are particularly important at the moment, as trainees are having to negotiate unfamiliar clinical situations, and may be required to exercise their ethical and clinical judgement in more unfamiliar situations. These group meetings should be held remotely.
  6. Consideration will need to be given to replacing lost experience in psychological therapies for trainees who are redeployed during the crisis.
  7. Staff support is more necessary during times of high stress and constrained resources. Existing staff support groups should continue remotely, and medical psychotherapists should take an active role in providing additional resources. The College has produced a list of messages for supporting healthcare staff during the epidemic.
  8. Other RCPsych guidance on COVID-19 includes ethical considerations and guidance on remote consultations.  
  9. A group of organisations involved in psychological therapies have drafted guidance for psychological professionals during the outbreak which members may find useful.
  10. Training: There is a new ARCP outcome 10 in response to the pandemic impact on trainee progression assessments which states: ‘Achieving progress and the development of competences/capabilities at the expected rate but acquisition of some capabilities delayed by impact of COVID 19. Can progress to next stage of training as overall progress may be satisfactory. Any additional training time will be reviewed at the next ARCP.’

     

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