Direct referrals from social services to community teams for older people with mental illness

AIMS AND METHOD

The aim of the study was to evaluate the open referral systemfrom social services to a community mental health team (CMHT)for older people. Referral letters from social services tothe specialist team were reviewed, as were the case notes.

RESULTS

Of the 40 referrals, 95% (n=38) were accepted by the CMHT. Only 15% (n=6) fulfilled the team’s existing referral criteria.The majority of referrals (n=36, 90%) had details of the patient’s mental health problems. None of the referrals with memory problemshad a cognitive assessment. Of the 38 referrals accepted bythe CMHT, 36 were found to be suffering from a mental illness.The open referral system from social services did not increasethe total number of annual referrals.

CLINICAL IMPLICATIONS

Social services play an important role in identifying and referringolder people with mental illness and ensure a potentially rapidreferral route bypassing primary care. The practice of acceptingdirect referrals from social services should be encouragedand made an integral part of the referral system.

Introduction

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Introduction

Most of the UK mental health teams for older people only acceptreferrals from general practitioners (GPs) or other medicalspecialties. Referrals directly from social services are generallynot accepted.

Reaching people with mental health problems early is an aimacross services and age groups (Rethink, 2002, 2004). Socialcare staff have contact with large numbers of older peopleearly on and are well placed to identify mental health problemsand facilitate early recognition and management (Manthorpe et al, 2004).

There is currently little information in the UK on the social worker’s ability to recognise mental health problemsin later life. Moriarty’s (2002) systematic review foundjust one study reporting on recognition rates of dementia.Cohen & Fisher (1987) found that social workers correctlyidentified approximately 65% of cases of dementia among peopleon their case-loads. More recently, Challis et al (2004) foundthat care managers were not aware of cognitive impairment atthe time of their client’s referral in 36% of their cases.

Method

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Method

The area of Broxtowe in Nottingham has a population of 19 177people aged 65 and over (Office for National Statistics, 2001).Approximately 80% of all patients referred to the Broxtowecommunity mental health team (CMHT) for older people by theirGPs receive a diagnosis of dementia with the remaining havinga functional illness. The team started accepting direct referralsfrom social services in April 2003.

All referrals from social services to the CMHT during a 2-yearperiod from May 2003 were identified. The referral letterswere reviewed for details of the patient’s mental healthproblems including reason for referral and assessment of cognition.Furthermore, it was also noted if the referral fulfilled theteam’s existing referral criteria (Box 1) and if thereferral was accepted or rejected. The case notes were thenreviewed to identify whether there was a diagnosis of mentalillness.

With the establishment of the open referral system from socialservices there were initial apprehensions within the team,particularly regarding the potential increase in referralsand workload. The total number of referrals in the 12-monthperiod following the start of the open referral system was comparedwith the number of referrals in the preceding year.

Box 1. Team’s existing referral criteria

Patients ofall ages with memory impairment as evidenced by a score of 25 or less on Mini-Mental State Examination.

Patients of 65 yearsor older who suffer from a functional psychiatric illness,which cannot be managed by primary care services.

Results

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Results

There were 55 direct referrals from social services to the team.Referral letters were missing for 9 referrals and in 5 instances,case notes could not be found. In one case the referral wasout of the area. Hence, the number of referrals evaluated was40.

Of the 40 referrals, 38 (95%) were deemed suitable for the specialist services and were accepted. The referral letters had detailsof the patient’s mental health problems and gave thereasons for referral to the CMHT for 36 patients (90%). Noneof the referrals with memory problems had an assessment ofcognition. Of the 38 referrals accepted by the team, only 6 (15%) fulfilled the team’s existing referral criteriaand these referrals were of patients with functional illnesses.On assessment, 36 (90%) of the referrals were found to be sufferingfrom a mental illness (Table 1).

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Table 1. Diagnosis

There was no increase in the overall number of referrals whencompared with the preceding year, before the open referralsystem from social services was introduced. There were 450referrals in the year following the start of the open referralsystem compared with 476 referrals in the preceding year.

Discussion

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Discussion

Social services often have contact with a large number of olderpeople and it was felt that accepting direct referrals wouldhelp identify older people with mental health problems earlyin their illness, thereby giving opportunity for early intervention.

The results of the study showed that the majority of the referralletters had details of the patient’s mental health problemsand the reasons for the referral to the specialist services,thereby reducing the chances of inappropriate referrals. Themajority of the referrals were accepted despite not fulfillingthe team’s existing referral criteria indicating thatthe teams existing referral criteria are inadequate and inneed of revision. Manthorpe & Iliffe (2005) revealed thatsocial workers are familiar with possible signs of early dementiaand tend to be aware of the problems that might indicate theneed for referral for assessment.

The results also showed that none of the referrals with memoryproblems had an assessment of cognition. Cognitive screeningtests may not be relevant, due to fair access to care servicescriteria (Department of Health, 2003), when dealing with peoplewith a significant level of vulnerability. However, there areadvantages in using a quick and easy to use standardised screening test like the Mini-Mental State Examination (Folstein et al, 1975) and Six-Item Cognitive Impairment Test (6-CIT) (Brooke & Bullock, 1999) for the less obviously vulnerable, who might be at an earlystage of a dementia.

The majority of the accepted referrals after assessment werefound to be suffering from a mental illness indicating thatsocial services are appropriately identifying and referringolder people with mental illness. The open referral systemdid not lead to an overall increase in referrals, suggestingthat patients referred by social services would have been referred by their GPs, but perhaps at a later stage.

Constant changes in social work practice have increased thenature and scope of the social worker’s role in the NationalHealth Service. They play an integral role in the planning,organisation, staffing, and coordination of health servicesfor older people and are in a unique position to detect mentalillness early and make efficient use of an open referral systemfor the benefit of our patients.

References

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