Specialised Services Policy: CP19 Specialised Services Policy for Tier 4 Child and Adolescent Mental Health Services

Transcription

1 Specialised Services Policy: CP19 Specialised Services Policy for Document Author: Specialised Planner, Women and Children Executive Lead: Director of Planner Approved by: Management Group Issue Date: 3 September 2014 Review Date: September 2017 Document No: CP19 Page 1 of 27

2 Document History Revision History Version No. Revision date Summary of Changes Updated to version no.: 0.7 Sept 2006 HCW CAMHS Commissioning Policy June 2012 Specialised Services Policy January 2013 Transferred to new template and 4.1 minor changes. 4.1 March 2013 Ratified through Chair s Action on 5.0 behalf of Management Group 5.0 August 2014 Reference to assessments by Youth Offending Teams added and change to wording for Forensic referrals /08/2014 Approved by Executive Board Ratified through Chair s Action on behalf of Management Group 6.0 Date of next revision September 2017 Consultation Name Date of Issue Version Number CAMHS Tier 4 Planning Meeting Network Leads CAMHS Advisor to the Welsh Government CAMHS Managers and Clinical Directors Revised version WHSSC Management Group WHSSC Management Group WHSSC Management Group Approvals Name Date of Issue Version No. WHSSC Distribution this document has been distributed to Name By Date of Issue Version No. WHSSC website Office Manager Tier 4 Services SSP WHSSC website Office Manager March Page 2 of 27

3 Policy Statement Background Summary of Access Criteria WHSSC is responsible for commissioning specialist Tier 4 child and adolescent mental health services (CAMHS). The services include: Day services; Community and other intensive therapy programmes (e.g. Community Intensive Therapy Teams); Specialist forensic CAMHS; Inpatient CAMHS services within Wales; and NHS funded CAMHS placements outside Wales. These include NHS funded specialist healthcare inpatient placements for learning disabilities patients. This Policy sets out the services commissioned and the process for access to Tier 4 services for mental health care for children and young people up to their 18th birthday. Responsibilities Providers and WHSSC will work together under the terms of this Policy to ensure that children and young people are treated fairly and equitably across Wales. Referrers should: Inform the patient that this treatment is not routinely funded outside the criteria in this policy; Refer via the agreed pathway. Clinician considering treatment should: Discuss all the alternative treatment with the patient; Advise the patient of any side effects and risks of the potential treatment; Inform the patient that treatment is not routinely funded outside of the criteria in the policy; and Confirm that there is contractual agreement with WHSSC for the treatment. In all other circumstances submit an IPFR. Page 3 of 27

4 Table of Contents 1. Aim Introduction Relationship with other Policies and Service Specifications Scope Definition Codes Access Criteria Clinical Indications Gatekeeping and process for out-of-area placements Exceptions Responsibilities Access Criteria Tier 4 Forensic Mental Health Services (FACTS) Clinical Indications Criteria for Referral Putting Things Right: Raising a Concern Equality Impact and Assessment Annex (i) Referral Pathway Annex (ii) Checklist Page 4 of 27

5 1. Aim 1.1 Introduction The document has been developed as the policy for the planning of for Welsh patients. These include NHS funded specialist healthcare inpatient placements for learning disabilities patients. The purpose of this document is to: Clearly set out the circumstances under which patients will be able to access services; Clarify the referral process; and Define the criteria that patients must meet in order to be referred. 1.2 Relationship with other Policies and Service Specifications This document should be read in conjunction with the following documents: Specialised Services Policy for Eating Disorders Specialised Services Policy for Gender Identity Specialised Services; and All Wales Policy: Making Decisions on Individual Patient Funding Requests (IPFR). Page 5 of 27

6 2. Scope 1. Purpose 2.1 Definition There is a four-tier concept for planning, commissioning and delivering CAMHS: Tier 1 Tier 2 Tier 3 Tier 4 Primary or direct contact services First-line specialist services provided by individual professionals from specialist CAMHS Second-line specialist services provided by teams of staff from within specialist CAMHS Very specialised interventions and care (this includes inpatient psychiatric services) Tier 4 services are part of the overall CAMH service and should work with families, local Tier 3 services and other agencies to provide seamless care for patients, in line with the principles of Breaking the Barriers: Meeting the Challenges (2010). Tier 4 specialist CAMHS offer services for patients with mental health issues which are complex and severe, who have not responded to other forms of treatment or who require specialist assessment and/or treatment. The patients generally suffer from a mental disorder or mental illness as classified under ICD 10, which include: Severe eating disorders; Psychotic disorders; Severe affective disorders including depression; Severe anxiety or emotional disorders; and Severe Obsessive Compulsive Disorder. This policy also covers services for patients requiring Tier 4 specialist healthcare learning disabilities placements. Services commissioned under this Policy include: Day services; Tier 4 CAMHS inpatient services provided within Wales; Tier 4 CAMHS inpatient services provided outside Wales; Tier 4 inpatient learning disabilities healthcare placements; Intensive community support and treatment services; and Page 6 of 27

7 The all-wales Forensic Adolescent and Consultation Treatment Service (FACTS). 2.2 Codes Severe Eating Disorders F50 Eating disorders F50.0 Anorexia nervosa F50.1 atypical anorexia nervosa F50.2 Bulimia nervosa F50.3 Atypical bulimia nervosa F50.4 Overeating associated with other psychological disturbances F50.5 Vomiting associated with other psychological disturbances F50.8 Other eating disorders F50.9 Eating disorder, unspecified Severe affective disorders F30-F39 mood [affective] disorders F30.- Manic episode F30.0 Hypomania Mania without psychotic F30.1 symptoms F30.2 Mania with psychotic symptoms F30.8 Other manic episodes F30.9 Manic episode, unspecified F31.- F31.0 F31.1 F31.2 F31.3 F31.4 F31.5 F31.6 Bipolar affective disorder Bipolar affective disorder, current episode hypomanic Bipolar affective disorder, current episode manic without psychotic symptoms Bipolar affective disorder, current episode manic with psychotic symptoms Bipolar affective disorder, current episode mild or moderate depression Bipolar affective disorder, current episode severe depression without psychotic symptoms Bipolar affective disorder, current episode severe depression with psychotic symptoms Bipolar affective disorder, current episode mixed Page 7 of 27

8 F31.7 Bipolar affective disorder, currently in remission F31.8 Other bipolar affective disorders F31.9 Bipolar affective disorder, unspecified F32.- Depressive episode F32.0 Mild depressive episode F32.1 Moderate depressive episode F32.2 F32.3 Severe depressive episode with psychotic symptoms Severe depressive episode without psychotic symptoms F32.8 Other depressive episodes F32.9 Depressive episode, unspecified F33.- F33.0 F33.1 F33.2 F33.3 F33.4 F33.8 F33.9 Recurrent depressive disorder Recurrent depressive disorder, current episode mild Recurrent depressive disorder, current episode moderate Recurrent depressive disorder, current episode severe without psychotic symptoms Recurrent depressive disorder, current episode severe with psychotic symptoms Recurrent depressive disorder, currently in remission Other recurrent depressive disorders Recurrent depressive disorder, unspecified F34.- Persistant mood [affective] disorders F34.0 Cyclothymia F34.1 Dysthymia F34.8 Other persistant mood [affective] disorders F34.9 Persistant mood [affective] disorder, unspecified F38.- Other mood [affective] disorders F38.0 Other single mood [affective] disorders F38.1 Other recurrent mood [affective] Page 8 of 27

9 F38.8 disorders Other specified mood [affective] disorders F39.X Unspecified mood [affective] disorder F06.3 Organic mood [affective] disorders F07.8 Other organic personality and behavioural disorder due to brain disease, damage and dysfunction Severe anxiety/emotional disorders F40 - F41 F40.- Anxiety disorders Phobic anxiety disorders F40.0 Agorophobia F40.1 Social Phobias F40.2 Specific (isolated) phobias F40.8 Other phobic anxiety disorders Phobic anxiety disorders, F40.9 unspecified F41.- F41.0 Other anxiety disorders Panic disorder [episodic paroxysmal anxiety] F41.1 Generalized anxiety disorder Mixed anxiety and depressive F41.2 disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified F06.4 Organic anxiety disorder Behavioural and emotional disorders with onset usually occuring in childhood and adolescence Except F91 as this categorises F90-F98 conduct disorders which are exempt under the CAMHS policy. F92is mixed emotional and conduct disorders and has been left in as I am unsure if it is required or not. F90.- F90.0 Hyperkinetic disorders Disturbance of activity and attention Page 9 of 27

10 F90.1 Hyperkinetic conduct disorder ( See above note - Not sure if required as it includes hyperkinetic disorder associated with conduct disorder) F90.8 Other hyperkinetic disorders F90.9 Hyperkinetic disorder, unspecified F92.- Mixed disorders of conduct and emotions F92.0 Depressive conduct disorder F92.8 F92.9 Other mixed disorders of conduct and emotions Mixed disorder of conduct and emotions, unspecified F93.- F93.0 F93.1 F93.2 Emotional disorders with onset specific to childhood Seperation anxiety disorder of childhood Phobic anxiety disorder of childhood Social anxiety disorder of childhood F93.3 Sibling rivalry disorder Other childhood emotional F93.8 disorders Childhood emotional disorder, F93.9 unspecified F94.- Disorders of social functioning with onset specific to childhood and adolescence F94.0 Elective mutism Reactive attachment disorder of F94.1 childhood F94.2 F94.8 F94.9 disinhibited attachment disorder of childhood Other childhood disorders of social functioning Childhood disorder of social functioning, unspecified F95.- Tic disorders F95.0 Transient tic disorder Chronic motor or vocal tic F95.1 disorder Combined vocal and multiple motor tic disorder [de la F95.2 Tourette] Page 10 of 27

11 F95.8 Other tic disorders F95.9 Tic disorder, unspecified F98.- Other behavioural and emotional disorders with onset usually occuring in childhood and adolescence F98.0 Nonorganic enuresis F98.1 Nonorganic encopresis Feeding disorder of infancy and F98.2 childhood F98.3 Pica of infancy and childhood F98.4 Stereotyped movement disorders F98.5 Stuttering [stammering] F98.6 Cluttering Other specified behavioural and emotional disorders with onset usually occuring in childhood and F98.8 adolescence Unspecified behavioural and emotional disorders with onset usually occuring in childhood and F98.9 adolescence Severe OCD F42.- Obsessive-compulsive disorder F42.0 F42.1 F42.2 F42.8 F42.9 Predominantly obsessional thoughts or ruminations Predominantly compulsive acts [obsessional rituals] Mixed obsessional thoughts and acts Other obsessive-compulsive disorders Obsessive-compulsive disorder, unspecified Psychotic disorders F23.- Acute and transient psychotic disorders F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia F23.2 Acute schizophrenia-like psychotic disorder F23.3 F23.8 Other acute predominantly delusional psychotic disorders Other acute and transient psychotic disorders Page 11 of 27

12 F23.9 Acute and transient psychotic disorder, unspecified F25.- F25.0 F25.1 F25.2 Schizoaffective disorders Schizoaffective disorder, manic type Schizoaffective disorder, depressive type Schizoaffective disorder, mixed type F25.8 Other schizoaffective disorders Schizoaffective disorder, F25.9 unspecified F28.X Other nonorganic psychotic disorders F29.X F22.0 F84.0 F84.1 Unspecified nonorganic psychosis Delusional disorder (some patients recorded with this may have a diagnosis of paranoid psychosis - but not all) Childhood autism (some patients recorded with this may have a diagnosis of infantile psychosis - but not all) Atypical childhood autism (some patients recorded with this may have a diagnosis of atypical infantile psychosis - but not all) F53.1 Severe mental and behavioural disorders associated with the puerperim, not elsewhere classified (some patients recorded with this may have a diagnosis of puerperal psychosis NOS - but not all) F09.X Unspecified organic or symptomatic mental disorder (some patients recorded with this may have a diagnosis of organic psychosis NOS - but not all) F06.0 Organic hallucinosis F06.2 Organic delusional [schizophrenia-like] disorder Page 12 of 27

13 F06.8 Other specified mental disorders due to brain damage and dysfunction and to physical disease (some patients recorded with this may have a diagnosis of organic psychosis NOS - but not all) NOTE (1): Due to the wording of the CAMHS policy mental health problems caused by substance misuse have NOT been included on this list of codes. If they are required please advise of this. NOTE (2): Mental health issues caused by specific diseases (i.e. Dementia, Creutzfeldt-Jakob disease, etc) have NOT been included on this list of codes. If they are required please advise of this. Page 13 of 27

14 3. Access Criteria 3.1 Clinical Indications In order to access Tier 4 specialist services, an assessment must be carried out by a Tier 3 CAMHS Psychiatrist. The child or young person should be suspected of requiring treatment or further specialist assessment for a severe mental disorder or illness. It is recognised that admitting children to hospital for psychiatric care can be traumatic for children and their families. All communitybased alternatives to admission must be considered before an assessment by Tier 4 services is requested, although it is acknowledged that at present community-based alternatives vary in provision across Wales. In practice there are often choices to be made about which service is most likely to be of benefit to the patient, taking all views (service user, their family and referrer) into account. This will be informed by the level of risk to the patient and community, and by the local services which are available. The clinical assessment to determine suitability for offenders should take account of any recent assessments carried out by Youth Offending Teams (YOTs). Referrers are encouraged to discuss these issues with the Tier 4 service in either North or South Wales and a joint approach should be agreed. The Tier 4 inpatient CAMHS units commissioned by WHSSC within Wales are: South Wales and South Powys - Ty Llidiard, Bridgend, Cwm Taf Health Board North Wales and North Powys - North Wales Adolescent Service, Abergele Hospital, BCUHB Community intensive treatment teams are available in the Cwm Taf HB, Cardiff and Vale UHB and Abertawe UHB areas. Discussions are ongoing regarding the establishment of a community intensive treatment model across the whole of Wales. Page 14 of 27

15 3.2 Assessment for Referral Where patients are assessed as potentially requiring a Tier 4 service by the Tier 3 service, the gatekeeping arrangements should be followed, even if the local unit is full, in order to provide advice on the care plan for the patient. These gatekeeping arrangements are included in section 3.3. The standards for assessment and admission are laid out by the Welsh Government and are: To ensure children and YP who are assessed by Specialist CAMHS are requiring admission to a psychiatric unit for adolescents on account of their clinical needs are assessed for admission within 2 weeks from the date on which a referral is dispatched and if admission is considered necessary, it occurs within a further 2 weeks; and To ensure children and YP who are assessed by Specialist CAMHS as requiring immediate admission to a psychiatric unit for adolescents on account of their clinical needs are assessed for admission within 12 hours from the date of the time at which a referral is dispatched or a telephone referral is made and if immediate admission is considered necessary, it occurs within a further 24 hours. If a non-immediate admission is agreed, it occurs with a further 2 weeks. These standards are no longer part of the AQF dataset and as such should be monitored locally by each LHB. They will be audited annually by WHSSC. 3.3 Admission criteria for CAMHS Tier 4 services provided in Wales There are no Tier 4 learning disabilities or inpatient forensic services provided by the NHS in Wales. The criteria below apply to admission for Tier 4 CAMHS inpatient care and the community intensive support and treatment services provided within the NHS in Wales. Referral to the NHS Tier 4 service should only be considered when: 1. There is no viable alternative within the local provision of care and all other options have been exhaustively considered; 2. Inpatient care, or intensive community treatment is the least restrictive, effective and safe option available to manage the clinical situation; and Page 15 of 27

16 3. The patient meets the referral criteria for the Tier 4 service. The referral criteria are: 1. The child or young person is aged between 12 and 17 years old (inclusive); 2. The child or young person has, or is expected to have on more detailed assessment, a primary psychiatric disorder; 3. The patient does not have a moderate or severe learning disability; 4. The primary issue is not alcohol or substance misuse; 5. Forensic issues Young people who are serving statutory community sentences or have a history of offending behaviour are not excluded however offending behaviour (such as sexual offending or serious/persistent violent offending) that would put other young people and staff members at risk, and cannot be managed on the ward, are absent; 6. The primary issue is not a conduct disorder; and 7. Secure psychiatric care is not required. 8. If care is voluntary, the child themselves must accept the treatment offered and be capable of using the treatment offered. This includes: a. The child having sufficient intellectual and verbal capacity to take part in the ward routine and treatments offered. b. The child is not likely to place others at undue risk within the environment; or 9. If care is involuntary: a. the patient may be admitted for assessment to inform the ongoing care plan. or b. the disorder must be treatable, or the disorder capable of amelioration and c. the admission must be in line with the provisions of the Mental Health Act 1983 and Gatekeeping and process for out-of-area placements The commissioning strategy for CAMHS Tier 4 services for Welsh residents is to ensure that children and young people are treated within Wales wherever possible. However it is recognised that there are certain groups of patients for whom, at assessment, an out-ofarea placement may be recommended in the patient s best interests Page 16 of 27

17 as the inpatient units in Wales may not offer the required specialist care. These are as follows: Patients who are assessed as too high risk for admission to an NHS inpatient unit in Wales; Patients who require secure accommodation; Patients who require specialist placements for unusual or very complex conditions; Patients who are under 12 years of age; and Patients whose placement needs are primarily related to a learning disability. From time to time, patients may also need to be placed out-of-area due to capacity restraints in the local unit Gatekeeping All alternatives to an out-of-area placement must be considered before an application for a placement is made. Where the issue is of lack of available capacity in the local Unit, consideration must be given as to when the next discharge from the Unit is expected, and whether a plan can be put in place to keep the child safe in an appropriate local setting pending a place becoming available. A discussion should take place to consider the out-of-area placement between the referring Consultant and the Gatekeeper. The Gatekeeper may ask other specialists to help inform opinion where the patient has very specialist or complex needs (e.g. learning disabilities, very young children, rare or unusual cases). Gatekeepers are as follows: Tier 4 CAMHS South Wales and South Powys Clinical Director, CAMHS Managed Network, Cwm Taf North Wales and North Powys Tier 4 Lead Clinician, North Wales Adolescent Service, BCUHB Forensic patients requiring secure placements All Wales Lead Clinician All-Wales FACTS service Learning Disabilities patients Page 17 of 27

18 There are no Tier 4 Learning Disabilities services in Wales, referrals should be made by a Tier 3 Child and Adolescent Learning Disabilities Consultant. If it is jointly agreed that an out-of-area placement is required, the referring Consultant should complete the all-wales IPFR form and send it to WHSSC. This should include details of the recommended placement and costs. The Gatekeeper should provide a letter or to confirm that all alternatives have been considered, and their support for the out of area referral. Once all of the completed paperwork is received, WHSSC will undertake to process the applications in a timely manner that meets the needs of the patient. Wherever possible, urgent cases will be dealt with on the same working day, whereas non-urgent cases will be considered at the weekly screening panel. WHSSC will normally agree placements for a maximum period of three months in each instance. Where the patient has been placed due to lack of capacity in the local unit, this period may be considerably shorter, on the basis that the patient should be repatriated as soon as possible Disputes Where an agreement is not initially reached between the Tier 3 and Tier 4 services, a clinical meeting should be held with all parties to agree the way forward. This may include other relevant parties such as adult mental health services or learning disabilities services where appropriate. WHSSC will not adjudicate in these clinical decisions. An IPFR application should not be made until the management plan is jointly agreed between Tier 3 and Tier Review of the placement The patient s Tier 3 clinician will be responsible for reviewing the placement whilst the patient remains in the out-of-area placement. WHSSC will ask the Tier 3 clinician to review the placement when the funding agreement is due to expire. The Tier 3 clinician should ensure that relevant meetings regarding the patient are attended, including CPA meetings. The Tier 3 clinician should provide a full clinical update, including consideration of whether it would be appropriate to repatriate the child, in a Page 18 of 27

19 timely manner for a decision to be made regarding an extension of the funding. The Tier 3 clinician should maintain contact with the patient to ensure that they are receiving the agreed service. If governance issues arise regarding the placement, WHSSC and the relevant senior managers within the referring LHB should be notified immediately. The Tier 3 clinician will be responsible for co-ordinating the discharge plan when the patient is ready to return from the placement. 3.5 Exceptions If the patient does not meet the criteria for treatment, but the referring clinician believes that there are exceptional grounds for treatment, an Individual Patient Funding Request (IPFR) can be made to WHSSC under the All Wales Policy for Making Decisions on Individual Patient Funding Requests (IPFR). If the patient wishes to be referred to a provider out of the agreed pathway and the referring clinician believes that there are exceptional grounds for treatment at an alternative provider, an Individual Patient Funding Request (IPFR) can be made to WHSSC under the All Wales Policy for Making Decisions on Individual Patient Funding Requests (IPFR). Guidance on the IPFR process is available at Responsibilities Referrers should: Inform the patient and their legal guardian that this treatment is not routinely funded outside the criteria in this policy; and Refer via the agreed pathway. Clinician considering treatment should: Discuss all the alternative treatment with the patient and their legal guardian; Advise of any side effect and risks of the potential treatment; Inform the patient and their guardian that treatment is not routinely funded outside of the criteria in the policy; and Page 19 of 27

20 Confirm that there is contractual agreement with WHSSC for the treatment In all other circumstances submit an IPFR request. 4. Access Criteria Tier 4 Forensic Mental Health Services (FACTS) 4.1 Clinical Indications Forensic mental health has been defined as an area of specialisation that involves both the assessment and treatment of those who are mentally disordered and whose behaviour has led or could lead to offending. Tier 4 specialist forensic mental health services are commissioned by WHSSC and provided by the all-wales Forensic Adolescent Consultation and Treatment Service (FACTS). This is a community-based service. There are no forensic healthcare inpatient services for children and young people within Wales. 4.2 Criteria for Referral The FACTS service has four main commissioned responsibilities within the arena of forensic CAMHS: 1. Providing consultation and advice to staff of Specialist CAMHS 2. Providing training for practitioners in Specialist CAMHS 3. Providing direct clinical services, alongside specialist CAMHS, for some young people in response to selected and negotiated referrals; and 4. Providing consultation, advice and training to the staff of certain other agencies. The referral criteria for the service are: The young person must be aged between 10 and 17 years old (inclusive); The young person presents with a severe disorder of conduct and emotion, neuro-psychological deficits or serious mental health problems and exhibits dangerous, high risk behaviours and who has become (or is likely to become) involved in criminal proceedings; and Page 20 of 27

21 The young person presents a high risk to others through such behaviours as fire-setting, physical assault and sexual offending. 4.3 Referral Pathway Referrals to the Forensic Adolescent Consultation and Treatment Service (FACTS) must be made by a CAMHS Psychiatrist and may come from any LHB area for assessment. If accepted, the FACTS team will advise the appropriate treatment and can in certain circumstances provide direct care alongside the CAMHS team. If the FACTS team advises that an inpatient placement is required, the procedure as outlined in section 3.4 should be followed. Page 21 of 27

22 5. Putting Things Right: Raising a Concern Whilst every effort has been made to ensure that decisions made under this policy are robust and appropriate for the patient group, it is acknowledged that there may be occasions when the patient or their representative are not happy with decisions made or the treatment provided. The patient or their representative should be guided by the clinician, or the member of NHS staff with whom the concern is raised, to the appropriate arrangements for management of their concern: When a patient or their representative is unhappy with the decision that the patient does not meet the criteria for treatment further information can be provided demonstrating exceptionality. The request will then be considered by the All Wales IPFR Panel. If the patient or their representative is not happy with the decision of the All Wales IPFR Panel the patient and/or their representative has a right to ask for this decision to be reviewed. The grounds for the review, which are detailed in the All Wales Policy: Making Decisions on Individual Patient Funding Requests (IPFR), must be clearly stated. The review should be undertaken, by the patient s Local Health Board; When a patient or their representative is unhappy with the care provided during the treatment or the clinical decision to withdraw treatment provided under this policy, the patient and/or their representative should be guided to the LHB for NHS Putting Things Right. For services provided outside NHS Wales the patient or their representative should be guided to the NHS Trust Concerns Procedure, with a copy of the concern being sent to WHSSC. Page 22 of 27

23 6. Equality Impact and Assessment The Equality Impact Assessment (EQIA) process has been developed to help promote fair and equal treatment in the delivery of health services. It aims to enable Welsh Health Specialised Services Committee to identify and eliminate detrimental treatment caused by the adverse impact of health service policies upon groups and individuals for reasons of race, gender re-assignment, disability, sex, sexual orientation, age, religion and belief, marriage and civil partnership, pregnancy and maternity and language (welsh). This policy has been subjected to an Equality Impact Assessment. The Assessment demonstrates the policy is robust and there is no potential for discrimination or adverse impact. All opportunities to promote equality have been taken. Page 23 of 27

24 Annex (i) Referral Pathway Voluntary org/ paeds/gp/ Social services/ Education Tier 2/3 CAMHS Potential need for patient to access Tier 4 Specialist Service Patient assessment must be carried out by Tier 3 clinician Yes Are community based alternatives suitable and available to support patient? No Referral made by CAMHS Psychiatrist to CITT team Referral made by CAMHS Psychiatrist to Tier 4 specialist service Yes Does patient fit CITT criteria? No Patient reviewed and assessed by Tier 4 Clinician Treated by CITT team Yes Potential need for patient to access Tier 4 Specialist Service? No Does patient fit Tier 4 Specialist service criteria? Referral made to Tier 4 specialist service Patient referred back to Tier 3 service Yes Admitted to Tier 4 specialist service No Potential need for patient to be placed No in a service out of area? Patient reviewed and assessed by Tier 4 Clinician Yes No Does patient fit Tier 4 criteria Patient reviewed and assessed by Tier 4 Clinical Gatekeeper Patient referred back to Tier 3 service Yes Admitted to Tier 4 specialist service No Patient reviewed and assessed by Tier 4 Clinical Gatekeeper Referring Tier 3 clinician to complete IPFR form with: Placement, cost and length of placement Support letter from T4 clinician Out of area proforma And send to WHSSC Referring Tier 3 clinician to complete IPFR form with: Placement, cost and length of placement Support letter from T4 clinician Out of area proforma And send to WHSSC WHSSC to consider and sign off funding if approved WHSSC to consider and sign off funding if approved Patient admitted to out of area placement Patient admitted to out of area placement Referring Tier 3 clinician to continue monitoring patient with clinical team at placement and laise with Tier 4 clinicians and continuing healthcare regarding needs including transition planning Referring Tier 3 clinician to continue monitoring patient with clinical team at placement and laise with Tier 4 clinicians and continuing healthcare regarding needs including transition planning Referring consultant to apply via form for extension(s) of placement required before funding for initial placement expires Referring consultant to apply via form for extension(s) of placement required before funding for initial placement expires Page 24 of 27

25 Annex (ii) Checklist CP19 Child and Adolescent Mental Health Services The following checklist should be completed for every patient to whom the policy applies: i) Where the patient meets the criteria AND the procedure is included in the contract AND the referral is received by an agreed centre, the form should be completed and retained by the receiving centre for audit purposes. ii) The patient meets the criteria AND is received at an agreed centre, but the procedure is not included in the contract. The checklist must be completed and submitted to WHSSC for prior approval to treatment. iii) The patient meets the criteria but wishes to be referred to a non contracted provider. An Individual Patient Funding Request (IPFR) Form must be completed and submitted to WHSSC for consideration. iv) The patient does not meet criteria, but there is evidence of exceptionality. An Individual Patient Funding Request (IPFR) Form must be completed and submitted to WHSSC for consideration for treatment. Page 25 of 27

26 To be completed by the referring gatekeeper or treating clinician The following checklist should be completed for all patients to whom the policy applies, before treatment, by the responsible clinician. Please complete the appropriate boxes: Patient NHS No: Patient is Welsh Resident Patient is English Resident registered with NHS Wales GP Post Code: GP Code: An assessment must be carried out by a Tier 3 CAMHS Psychiatrist. All community based alternatives to admission should be considered before an assessment by Tier 4 is requested. (it is acknowledged that at present community based alternatives vary in provision across Wales). The criteria below apply to admission for Tier 4 CAMHS inpatient care and the community intensive support and treatment services provided within the NHS in Wales. Referral to the NHS Tier 4 service should only be considered when: 1. There is no viable alternative with the local provision of care and all other options have been exhaustively considered; 2. Inpatient care, or intensive community treatment is the least restrictive, effective and safe option available to manage the clinical situation; and 3. The patient meets the referral criteria for the Tier 4 Service. Patient meets following access criteria for treatment: The child or young person is aged between 12 and 17 years old (inclusive); The child or young person has, or is expected to have on more detailed assessment, a primary psychiatric disorder; The patient does not have a moderate or severe learning disability; Forensic issues including offending behaviour (including violence or sexual offending) that would put other young people and staff members at risk, and cannot be managed on the ward, are absent; The primary issue is not a conduct disorder; Secure psychiatric care is not required. If the care is voluntary, the child themselves must accept the treatment offered and be capable of using the treatment offered. This includes: - The child having sufficient intellectual and verbal capacity to take part in the ward routine and treatments offered. - The child is not likely to place others at undue risk within the environment ; or If care is involuntary: - the patient may be admitted for assessment to inform the ongoing care plan or; - the disorder must be treatable, or the disorder capable of amelioration and; - the admission must be in line with the provisions of the Mental Health Act 1983 and Yes No Page 26 of 27

27 Patient wishes to be referred to non-contracted provider If the patient wishes to be referred to a non-contracted provider an Individual Patient Funding Request (IPFR) must be completed and submitted to WHSSC for approval prior to treatment. The form must clearly demonstrate why funding should be provided on the basis of exceptionality. The form can be found at Patient does not meet access criteria but is exceptional An Individual Patient Funding Request (IPFR) must be completed and submitted to WHSSC for approval prior to treatment. The form must clearly demonstrate why funding should be provided as an exception. The form can be found at Name: Designation: Signature: Date: Authorised by TRM Gatekeeper Authorised by WHSSC Patient Care Team Authorised by Tier 3 gatekeeper Patient Care Team/IPFR/TRM Reference number: Name (printed): Signature: Date: Yes No Page 27 of 27