'Thinking outside the box: alternatives to standard inpatient mental health care' by Amber Jarvis

c/o The Mental Elf on 'X' I came across a blog post by Amber Jarvis:

Thinking outside the box: alternatives to standard inpatient mental health care

Amber's post considers a study by:

Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/

At an online meeting this evening, near the close the discussion loosened and alighted on AI. The ability of AI to summarise a large text file, a *.pdf and create discrete web HTML pages. The racial bias 'built-in' by human coders, reflected in outputs; that point to structural racism. 

Finding this paper on X, boxes are the bread and butter of Hodges' model. Not just thinking outside a box, or inside one, but several and with a final twist - to follow. Amber begins:

'Inpatient mental health care involves staying in a hospital or specialised facility to receive intensive, round-the-clock support for serious mental health needs (Staniszewska et al., 2019). Whereas acute inpatient services typically respond to immediate crises, longer-term wards support individuals with more complex needs and a higher level of ongoing risk.

Inpatient services are a core component of our mental health system — whether someone stays for a night, weeks, or even several years. However, inpatient care has recently come under growing scrutiny – and for good reason.'

A Community Mental Health Nurse since 1985, my in-patient experience is a tad misty, but not misty-eyed. As the wards: psychogeriatrics, long-stay, female acute admission were simultaneously challenging, rewarding - in the sense of being able to make a positive difference, changing what were institutionalised practices, no personal clothes, lockers, tea urn, no banking, few visitors (admission wards excepted). It was all very quotidian: check the bath book. Then tell, confirm, assure the patient, 'yes!'. It is your bath day. I've posted previously about critical mental health. You do (should?) quickly learn you are part of a system, a machine; and the distinction between person- patient-centred and service-centred care. The need to do my 'general' quickly emerged too. 

As ever, two words, across Amber's post and Griffith et al's title, stand out; 'map' and 'typology'. I must revisit and post about:

Macduff C. (2007). Typologies in nursing: a review of the literature. Nurse researcher, 14(2), 40–50. https://doi.org/10.7748/nr2007.01.14.2.40.c6020

Part-time work since 2020, in two adult CMHTs and a recovery team, has provided an update. The first as COVID emerged, was a bit of a shock in terms of diagnoses, caseness, the proximity to the law and forensic psychiatry, thresholds for referral, changes to mental health law (that were now more practical) and the management of patient's finances. 

So, to return to last night's brief online discussion, the observation of how racism is ongoing, brought up the fact of racism being structural and institutional (Dean & Thorpe, 2022). The change needed is an intergenerational break, which doesn't bear thinking about. The National HEALTH Service faces the same challenges in the shift to prevention, and addressing racism. Where is the workforce, going to come from, to help recovery, health and related literacies (media, emotional, financial)?

It is easy in boxes like Hodges' model (and others) to be idealistic. Ideally as I learned of Community Psychiatric Nurses being recruited, six of us, we all should have asked:

What is the plan?

What is the model of care?

What characterises 'care in the community'?

How do we prevent relapse, readmission?

Is there a 'halfway house'*?

We did, to an extent. There was great enthusiasm, motivation, idealism, co-ordination, collaboration  (Tyrer & Gelder, 1990) and leadership. 'We' had an association,^ and a journal. Back then the Royal College of Psychiatry produced a report on CPNs. Is there a message in this? Progress was and has been made, but the promise has not been delivered. With care in the community having regressed, an incomplete 'project'.

I will read more and revise this post, or more likely add another: with less 'history' ...

Individual

|

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :    POLITICAL 

|

Group

Model of Care	Model of care
Model of Care Care in Community Children - Schools - Education	Model of care 'Care Leavers'

*'Cross-settings' in Griffith et al.

^https://www.unitetheunion.org/what-we-do/unite-in-your-sector/health-sector/mental-health-nurses-association

Lorraine T Dean, Roland J Thorpe, What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers, American Journal of Epidemiology, Volume 191, Issue 9, September 2022, Pages 1521–1526, https://doi.org/10.1093/aje/kwac112

Tyrer P, Gelder M. The future of community psychiatric nursing: some research findings. Psychiatric Bulletin. 1990;14(9):550-551. doi:10.1192/pb.14.9.550

ii 'Thinking outside the box ...'

iii 'Thinking outside the box ...'

See also: 'institution' : 'racism' : 'typology' : 'map' : 'Forensic'

c/o The King's Fund: Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England

When I see a 'model' I ask myself; what does this mean in itself? What is its purpose? I also (invariably) ask how does it relate to, or how might it support the theory and application that might underpin h2cm?

In February 2018 The King's Fund posted this item on integrated care systems. It wasn't just the 2x2 figure that caught my eye, but the axes and the additional amber tab (figure 1). Pondering for a time I have transposed this to Hodges' model below figure 1. Beneath that, I've provided an explanation for the altered schematic; recognising that as with h2cm such models are idealised representations.

c/o The King's Fund

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Individual care management Care for patients presenting with illness or for those at high risk of requiring care services	Population Health (systems) Improving health outcomes across whole populations including the distribution of health outcomes [Improving population health outcomes requires multiple interventions across systems]
'Making every contact count' Active health promotion when individuals come into contact with health and care services	Integrated care models Co-ordination of care services for defined groups of people (eg. older people and those with complex needs)

INTRA- INTERPERSONAL:
Individual care management has been changed from care services and individuals to this domain, which conceptually preserves the original placement. In h2cm as can be seen the interpersonal domain combines the individual and humanistic. In the 4Ps this domain also includes 'purpose'. Whenever possible it here (individual motivation) that self-care and self-efficacy and staying as well as possible relies on the patient's awareness and education about their condition and level of health literacy. There is recognition now that children need some awareness of mental health issues and the law needs to protect what images and content youngsters are exposed to on social media. So, ultimately 'how I manage myself' has a major bearing on the 'whole care management enterprise.' The focus on 'high risk' also denotes a need for an assessment and one that is part of the move to parity of esteem in respect of physical and mental health.

SCIENCES:
I have shifted Population Health (systems)from population to this (physical) individual domain, on the basis that our research, as in, quantitative and qualitative, needs to be synthesized and then ultimately generalised - across populations. While complex systems cannot be taken apart it is from the sciences (including social sciences) that evidence-based practice flows. There should be a feedback loop here, research that also takes into account the multiple interventions across systems (the amber tab in figure 1) and the outcomes achieved.

POLITICAL:
The King's Fund's figure 1 stands as it is of course, but I have 'moved' Integrated care models most radically. If there is no organisation, rules, order, policy, procedures ... then things will NOT happen (as they should). Agreement is also needed on definitions for reasons of standards, measures and accountability. Such matters are political (even if ignored - kicked in the long-grass). For services that are evidence-based (as just mentioned in SCIENCES) we need when possible for health and social care policies to also be evidence-based (for reasons of efficiency, equity, effectiveness and equality). While we cannot 'break' complex systems we can break models; 'health care systems' need to break ("be broken whilst still in flight") in order to be transformed for the 21st century.

SOCIOLOGY:
Making every contact count I have placed in the h2cm's Sociology domain. To me this initiative remains with care services, but I have switched this from individual to group-population within h2cm. Health care education places constant emphasis (research, CPD, mandatory training) upon interpersonal - communication skills and this is where clinical and social care interactions and interactions ultimately count. It is here that trust, the 6Cs, unconditional positive regard ... are 'counted' in qualitative terms. If the psychological represents the theory of psych-social intervention, it is in the social outcomes and benefits were the practice is (truly) delivered. It is also here that partnerships are forged and social capital found.

In social care as an example, the integrated care model should politically permit - allow for a sufficiently skilled and remunerated work-force (socially valued?) with sufficient time to ensure that every contact really does count.

<>

Forty years in the NHS suggests that when ever 'integrated care' is being written and even spoken about, then the context should be indicated at the same time; so at least - integrated care^1-5 as above?

'integrated' as in -

• philosophy (ethics, morality, values)
• spiritual (values) (and part-whole of 1-5)
• political - policy, government funding
• economically - commissioning (models of care, sustainability)
• management
• care delivery
• team organisation
• community involvement
• patient involvement
• health literacy, health promoting

...?

Accessibility: apologies that there is no equivalent text to figure 1.

My source: https://twitter.com/TheKingsFund/status/1093556280248147969

"Model hospital": Where to find 5mins per shift? (footprints - transformation?)

individual

|

INTERPERSONAL : SCIENCES

humanistic ---------------------------------------  mechanistic

SOCIOLOGY : POLITICAL

|

group

Mental health	8,500 beds blocked costing NHS providers around £900m per year 5 mins
Social care	Operational productivity and performance in English NHS acute hospitals: Unwarranted variations £280m delayed transfers of care independent sector expenditure costs £482m lack of data (still!) Stepdown facilities

"On staff rosters, Lord Carter said he found cases in which trusts were squeezing nurses on to weekday shifts in order to make up their weekly hours, and said 

 improving productivity by five minutes per shift could save as much as £280m." (p.11)

<>

Model - hospital : Model - community care : Model - self-care?

Scope of disciplines

Scope of nursing... (draft paper)

Scope of footprints

Scope of transformation?

Additional link:
NHS England (March 2016) Sustainability and Transformation Plan footprints, Ref: 04902.

My source: 

Dunhill, L. (2016) Carter: be masters of your fate, Health Service Journal, 10 February, 126: 6475, 10-11.

Innovation & Change: Pick an edge, any edge...

individual

INTERPERSONAL : SCIENCES

humanistic ------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

group-population

PURPOSE ...  "change always starts with the activists  and it always starts at the edge". p.23 subjective	PROCESS "Very often our change management approaches aren't very sophisticated. We'll pretend this change is an objective process when it can't be."  Endless transformation using the same processes is another well trodden path. p.23   objective
PRACTICE	POLICY  "... there is no clearly understood model for how services can adapt to changing population needs." p.23

Gbadamosi, N. (2015) Turn the tables on top-down change, Health Service Journal, 16 January, 125, 6430: pp. 22-23.

KT-EQUAL events: inc. Food and Nutrition in Later Life; Meeting the Needs of People Living with Dementia and their Carers ...

Dear KT-EQUAL supporters,
(Several other posts relating to SPARC and KT-EQUAL have been deleted, this has been retained for personal archive purposes. I learned a lot in attending some events organised under the auspices of this research programme, which stemmed from the IDEAS Factory in 2006.)

Hello. Here's an update about some of our activities and other news that may be of interest to you.

-----------------------------------------

Upcoming events programme
You are warmly invited to join our upcoming events:

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Food and Nutrition in Later Life
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When:    8 January 2013
Time:     9.30am - 16.15pm
Where:   University of Reading

The day features talks from experts, as well as an interactive "hands-on" showcase.  The event should be informative and fun, and provide an opportunity to meet and network with others who have personal or professional interests in food and nutrition for older people. The programme has been designed to appeal to a wide audience, including older adults, practitioners from health and social care, academic researchers, industry and charities.

Free to attend with lunch and refreshments included.

For further details and to book: ...

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Thinking outside the box - meeting the needs of people living with dementia and their carers
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When:    24 January 2013
Time:     9.00am - 16.45pm
Where:   The Forum, St James Parade, Bath, BA1 1UG

Dementia is a major challenge facing our health and social services over the next 20 years.  This has now been recognised by the government and significant resources are being directed towards early diagnosis, new treatments and management of people with dementia.

This funding will only be effective if we can develop news ways of supporting and managing people with dementia and there carers.  This will require a multidisciplinary team approach to problem solving and service delivery.  Health and Social Care Practitioners are familiar with the concept of multidisciplinary team working but often lack insights into dynamics of group working. We need to ensure that the interventions are effective and consider outcome measures that are appropriate for a long term neurodegenerative condition that are appropriate for patients and carers.

This event aims:

- to help researchers, health and social care professionals to think differently about meeting the needs of people who are living with dementia
- to consider the range of outcome measures that might be used to assess the benefit of an intervention
- to make researchers aware of the challenges and opportunities of multidisciplinary working
- to inform new researchers of the needs of people with dementia
- to trigger ideas for new research and provide a forum where participants can develop potential proposals

Please note that this event has limited places to ensure that representatives from several disciplines have the opportunity to participate.

Free to attend with lunch and refreshments included.

For further details and to register interest: ...

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Design for Living in Later Life
------------------------------------------
When:    31 January 2013
Time:     10.00am - 16.30pm
Where:   The Open University, Milton Keynes

This event brings together the latest research ideas and developments about creating lifetime environments for people of all ages.

Free to attend with lunch and refreshments included.

For further details and to book: ...
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Keeping safe and maintaining independence: older people and sight loss
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When:    7 February 2013
Time:     9.30am - 15.45pm
Where:   Weetwood Hall Conference Centre and Hotel, Otley Road, Leeds, LS16 5PS

This workshop event is concerned with sight loss in later life and how we can enable people to live a quality life despite the difficulties that arise from diminished vision.

This event aims to raise awareness of sight loss and its impact and to increase knowledge and understanding of how to support people with sight loss. The programme will showcase new developments in research and practice that have the potential to inform practitioners.

Free to attend with lunch and refreshments included.

For further details and to book: ...
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New posts on the KT-EQUAL blog which may be of interest to you:

Housing LIN newsletter – Housing with Care Matters, December 2012

This reflects back on some of the successes the Housing Learning and Improvement Network (LIN) had in 2012, including the recent 2nd annual conference attended by over 300 people.

The conference also saw Norman Lamb, Minister for Care and Support Services, announce an additional £40m in this financial year for Disabled Facilities Grants. Details of this and a number of other recent policy and funding announcements to do with housing, care and support are featured in this end of year newsletter along with information on new learning resources from the Housing LIN, important new publications such as HAPPI2, calls for information, and details of Housing LIN forthcoming regional meetings and events.

New dementia website launched: dementiakt.ca

The Canadian Dementia Knowledge Translation Network (CDKTN) and the National Core for Neuroethics are pleased to announce the launch of the online Dementia Knowledge Translation (KT) Learning Centre. This website is targeted towards new and established dementia researchers engaged in KT.

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Invitation to take part in a study

I am sending some details passed onto us by one of our members, based at TRL:

We are currently undertaking a European study regarding older road users and what different countries do about supporting mobility. The aim of our project is to investigate travel patterns and road safety amongst older road users across Europe, see how they are changing and look at what work is being undertaken to support improving mobility. As part of this we are looking to undertake interviews with possible major players as to what they are doing. Would anyone be interested in taking part in a telephone interview with one of our researchers on this topic?

If you are interested please contact Jenny Stannard, Principal Project Manager and Road Risk Consultant.
email: ...

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Recent Highlights

A new BBC film highlights the work of our i-design team in Cambridge: how do older people use technology? http://www.bbc.co.uk/news/technology-20664470

Falling off the Bandwagon: Sustaining digital engagement by older people - a series of consultation events have recently been undertaken exploring potential solutions to the challenges faced by older IT users. A major consultation event took place at St Georges House, Windsor focusing on solutions and how to implement them.  http://www.stgeorgeshouse.org/consultations/social-and-ethical-consultations/recent-consultations/

We were delighted that The Princess Royal presented a keynote address at our recent 'Showcase world class occupational therapy research to meet the needs of an ageing population' event. This event took place at the College of Occupational Therapists where The Princess Royal is Patron. It was a unique opportunity to bring together leading experts to discuss ways of meeting the challenges of an ageing population.
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I hope that this is helpful. It's been a pleasure to meet with some of you over the course of this year - look forward to further developments in 2013. If you have any queries and or comments/suggestions please do not hesitate to contact me.

As this eventful year draws to a close, we would like to thank you for all your continued support and extend seasons greetings.  All the very best for 2013.

Bangar
--------
S Bangar
KT-EQUAL Research Co-ordinator
School of Health and Related Research (ScHARR)
University of Sheffield
Regent Court, 30 Regent Street
Sheffield  S1 4DA

Report - Integrated care for patients and populations: Improving outcomes by working together

I've posted on integrated care previously on W2tQ. The core recommendations of this New Year  report on integrated care are:

• government policy should be founded on a clear, ambitious and measurable goal to improve the experience of patients and service users and to be delivered by a defined date
• patients with complex needs should be guaranteed an entitlement to an agreed care plan, a named case manager responsible for co-ordinating care, and access to telehealth and telecare and a personal health budget where appropriate
• change must be implemented at scale and pace; this will require work across large populations, significant reform and flexibility to take forward different approaches.

Publication prompted Time to integrate words with action by Chris Ham and Jennifer Dixon (HSJ 5 January pp. 16-17 - and my source for this news). The report and mention of measures of integrated care that include patient experience provoked further reflection.

Integration in health and social care should be considered critically over the past 25 years and more (but that's a thesis). Evolution in policy matters, but there is a deep archaeology that illustrates the policy aspiration - practice gap the reports priorities seek to address. A comment in response on the King's Fund's site notes the need for (strategies, methods and) a framework. While no magic wand there is a framework that can at least unify disciplines, public and policy makers. And act as a bridge between words and actions.

Integration needs a shared and agreed origin.

(A point* around which disintegration turns)

Although brief (20 pages) the report is an excellent source for references (3 pages) that includes:

Kodner D, Spreeuwenberg C (2002). ‘Integrated Care: Meaning, logic, applications, and implications – a discussion paper’. International Journal of Integrated Care, vol 2,
Available at: www.ijic.org/index.php/ijic/article/view/67 (accessed 13 December 2011).

Kodner D (2009). ‘All together now: a conceptual exploration of integrated care’. Healthcare Quarterly, vol 13(Sp), pp 6–15.

Leutz W (2005). ‘Reflections on integrating medical and social care: five laws revisited. Journal of Integrated Care, vol 14, no 5, pp 3–12.

As we try to integrate words and actions we need to remember:

how we dice and slice influences the scope of integration.

We'll explore this more soon.
*Points?

Nick Goodwin, Judith Smith, Alisha Davies, Claire Perry, Rebecca Rosen, Anna Dixon, Jennifer Dixon, Chris Ham Integrated care for patients and populations: Improving outcomes by working together. Report to the Department of Health and NHS Future Forum from The King’s Fund and Nuffield Trust

Report - Guiding patients through complexity: Modern medical generalism RCGP & The Health Foundation

Evaluation report

PUBLISHED: October 2011

Report of an independent commission for the Royal College of General Practitioners and the Health Foundation


An independent commission, chaired by Baroness Finlay, has concluded that more of the most talented doctors must be encouraged to make careers as generalists rather than specialists to meet people’s changing health needs.

The Commission was set up by the Royal College of General Practitioners and the Health Foundation to examine the state of general medicine. It had the following terms of reference:

• Define medical generalism, with particular reference to general practice;
• Explore the intrinsic values of medical generalism;
• Define the role and value of medical generalism in contemporary clinical practice.
• Formulate a description of the medical generalist that:
• Is widely recognised
• Defines what patients and the public should be able to expect
• Clarifies how the medical generalist interfaces with other health care professionals
• Make recommendations about the future development of medical generalism.

Understanding and developing the role of the generalist alongside specialists is important for the quality of patient care, particularly ensuring the health service provides patient centred care and supports people with co-morbidities well.

Lean machine(s): chasing the contexts

There is a perennial game in health and social care called assessment and evaluation: the game could also be called 'CTC' - 'chasing the context'.

Relativity lies not only in the realm of physics and philosophy.

When I say relativity I am referring of course to the influence and impact of a health and social care situation from the constantly changing perspective of each of several different players:

• the patient;
• carer;
• nurse;
• doctor;
• manager;
• medical ward;
• community mental health team;
• commissioner.

Usually, the context collapses to a specific problem (a situation) and the players set to solve a care problem presented by an individual -

• a client, resident or patient;

and their -

• relatives;
• residential care home manager;
• residential care home staff nurse and team;
• community mental health nurse;
• medical personnel.

Context directs, dictates, and shapes health and social care theory, practice, management and policy.

This relativism can also subvert, sublime, confuse and stymie plans, common sense notions, creativity, innovation and management directives.

Like a tide this relativity picks us up and re-figures, re-paints and shifts the location of everything - including measures and how they are used.

Context is all! - so the saying goes. But context never wholly reveals itself. For that is another situation, another context, another side, another coin.

For context there are key defining parameters (location, diagnoses, risk, need, physical, mental, holistic ...) all of these are couched or spring from time.

So, the game calls for us and the tide teases us to measure and evaluate. This coast is never clear, but how long is it now? Where are the pathways now? Where will they be again?

As we travel (and travail) to and from this context to that - thresholds are also altered: up and down and always around; the way of life and ..... .

Image source:
http://www.esd112.org/edtech/no_limit/rs_archive.cfm

h2cm - Being at the center of things [I]

The center of Hodges' model can represent many things:

an epistemological nexus for the transdisciplinary dependencies of our times
multidisciplinary coffee shop
self-care engagement stage
the chaos of all things
holistic harmony
integrated idyll*

More down to Earth and acknowledging this cruciform '+' structure as a mythic device, in addition to searching for the mysteries of the universe at the center we can also place the 'well' person there.

As the previous post on ADLs suggests the 'well' person can function on a basic level and has negotiated the four axes and the four and five fold knowledge domains. They can therefore be considered (sufficiently) wholly integrated. We are all travellers, constantly traversing these domains of experience consciously, unconsciously, expertly or with the awkwardness that denotes the novice.

Conversely and reflecting the model's utility: it is also possible to locate the unwell individual in the center too. In this instance the placement suggests impoverishment of experience, ongoing personal and social stasis and in the case of substance misuse the presence of specific disruptive focus and preoccupations. The person becomes lost to their potential, stuck in a 4:5-fold minima. They continue to travel chronologically, but the journey is spiral, self-iterative and diminishing by return.

However: what you can see you can change, or come to terms with.

*from Greek eidyllion, little picture (h2cm as a snapshot).

Original image source: http://www1.lsbu.ac.uk/water/protein2.html

Bee in my bonnet and a place to call home

For some years (over a decade) I've had a bee in my bonnet about the impact of relative-ly sudden house moves that older adults often make following sudden bereavement.

This prompted a first and no longer available website 'Beware Reflex Moves'.

This rather silent issue still stands and is arguably growing in volume.

There are surely a series of studies to be made here. Like most forms of life, the patient-nurse encounters of all those years ago have evolved: the ability of Jo(e) Public and their families to independently visit, select and move their relative into residential care is a new factor.

Self-funding frees up valuable resources as people can essentially circumvent the formal assessment processes of social services (and health), negotiating directly with the home of their choice for a place. This place may be many, many miles away from what was home. Amid increasing demand this arrangement works well much of the time. When it fails though, the impact is a personal and social catastrophe that can also reverberate across two health and social care economies. The person's original social services and their new location - that of their family.

Here the 'diagnosis' may not just be bereavement reaction / depression, but dementia too.

So, the advice remains beware of reflex moves.

Wish those bees had stayed in that bonnet - they might be safe now.....

Image source with thanks: http://www.flickr.com/photos/lelonopo/2378726643/

1st Contact: ET and care on the front line

ET as in 'extraterrestrial' may seem remote from nursing and health care, but where there's a will....

Health and social care appears to become ever more specialised with each turn of the policy machine. People's lives are experienced as being ever more complex. Health care is filled with uncertainty and the public present with multi-diagnostic, person-centred, choice bearing, (usually) recovery directed problems, needs and strengths.

Pity then the care workers on the front line, at the point of 1st contact. Like the baseball catcher it helps if they can field the knowledge and skills required to cover physical, mental health and possibly learning disabled clients. You have to hope that coaches recognise that Hodges' model can help the team be aware and fully prepared to cope with 1st contact supporting and facilitating what follows. So, how does your team get to grips with complex care?

Additional links:

Baileff, A. (2004) Developing high quality first contact nursing in Southampton NHS Walk-in Centres. At, Innovations in Partnership, Practice and Education, 3rd Annual Scholarship Conference, Portsmouth UK, 2 Jul 2004. Southampton, UK, University of Southampton. http://eprints.soton.ac.uk/9197/

Declaration of Principles Concerning Activities Following the Detection of Extraterrestrial Intelligence http://www.setileague.org/general/protocol.htm

Image and source: Louisville Slugger OXFB Omaha Pro Series 13 Inch First Base Baseball Mitt from
Formerly - anaconda sports

Transcultural health & Hodges model

Text by Larson et al. (2001) is presented below with a suggested placement of
Bradshaw's (1972) typology of social need on to the four care domains of Hodges' model:

Felt need: The needs as perceived by members of the group.	Normative need: The group fails to meet an objective, universalistic standard. Technical definitions of need such as the Australian National Mental Health Standards are examples of normative need.
Expressed need: Through their behaviour, group members have demonstrated a need, often by lengthy queues for services or failure to attend a service.	Comparative need: The group is demonstratively worse off than another group. Comparative need is usually demonstrated through routinely collected statistics, which is problematic for small ethnic groups whose identities are rarely recorded (p.336).

Bradshaw’s framework is still widely used. The important distinction is one between the ‘top-down’, professional-derived definitions of normative and comparative needs, on the one hand, and the felt and expressed needs, interpreted as the ‘bottom-up’ expression of experiences and attitudes, on the other (p.336).

See also Larson et al. discussion of 'thin' and 'thick' needs.

(The fact that this typology can be described in terms of 'top-down' - 'bottom-up' also highlights the socio-technical potential of Hodges' model.)

References:
Bradshaw, J. (1972). The concept of social need. New Society, 19(496), 640–643.
Larson, A., Frkovic, I., van Kooten-Prasad, M., Manderson, L. (2001). Mental Health Needs Assessment in Australia’s Culturally Diverse Society, Transcultural Psychiatry, 33(3), 333-347. Abstract

Holistic care: What is 'holistic bandwidth'?

The old website with its pages is static. In thinking about how to mix the old and create new dynamic content for a Drupal based site, I came across a possible way to define and explore our notions of holistic care. Here are some very initial musings....

First to focus on quantity. In completing an assessment whichever care domain I start in (let's say the intrapersonal domain) then as that domain is populated can it be argued that within the other domains the same number of placeholders for our assessment data are created? If my patient has eight problems (and two strengths) then according to one definition of holistic bandwidth the remaining domains should have the same number of problems (and strengths). Balance in all things - including holistic care?

One thing that the ADLs teach us is that (holistic) care as represented in Hodges' model is asymmetrical.

This does not mean that the ideal of holistic care is lost.

It might mean that strident efforts to assure holistic bandwidth can interfere with our attaining person-centred, integrated and multidisciplinary care.

It is essential that we recognise holistic care as an ideal, as a constraint and the primacy of functional considerations in:

• assessment;
• planning;
• care interventions;
• evaluation;
• and governance.

It comes as no surprise then that there are several versions of holistic bandwidth:

1. If we want to be inclusive then version #1 is epistemological. This anticipates the total number of semantically associated concepts that can potentially arise in a given care episode. This is what might be termed the 'semantic web of care'.
2. The sum total of concepts across all the care domains (inc. spiritual) that are actually activated in the course of a care episode.
3. The concepts that are deemed relevant by the patient, carer, family and guardians.... These add holistic value to and may well (must!) overlap with the care concepts recorded by the clinical team and reflected in the health record(s).
4. The degree of expressiveness of the care recording system - its capacity to represent holistic care and capture (measure) holistic bandwidth pre- or post- care episode completion.
5. The (idealised and learner generated) collections of care concepts identified and enacted within education.
6. The idealised and actual collections of holistic arrays applied and recorded by the combined clinical and social care disciplines* involved (there are two sets in practise and theory). As per #3 these (should) overlap with the patient and carer's....
7. The final combined lexis of written, electronic and other record(ed) media that constitutes the final:
• personal health record;
• summary health record;
• historical health record;
• clinical record;
• ....
• all the above combined;
• an individual and group's (family) health career!
8. In addition there are the anonymised and aggregated data items that form part of clinical / management reports, local, central government statistics and returns that inform national health and social care policy and global health intelligence at the WHO.
9. Throughout 1-8 holistic bandwidth must also incorporate education, engagement and informatics.

It is reasonable to speak of personal and impersonal forms of holistic bandwidth.

Students - if this is helpful or confusing please let me know h2cmuk @ yahoo.co.uk

Records 2: Flying the standard

'Records I' was posted last September, time to revisit this theme...

If I am a real champion of Hodges' model, convinced of the value and care-worthiness of this 21st century conceptual framework then why have I not been an agent of change@work?

Surely, I would not have stopped short of stepping on toes, or letting a lack of evidence get in the way of advocating the model as a solution to real problems? So why haven't I been the standard bearer where it really matters - on the shop floor? Excuses are many and include:

• the personal - part-time nature of my combined nursing-informatics interest;
• following local policy Care Programme Approach [CPA];
• professional accountability - risk assessment and management and working as a CPA lead;
• watching with interest as the Single Assessment Process joined the fray;
• and even more recently the Common Assessment Framework;
• plus, and this may be a cop out - I like people to decide/discover things for themselves.

Having been away from the clinical practice from Nov 2004 to last summer I was informed as to how much things had changed. After a short period of time I realised on the contrary how little things had changed.

We are still completing paper documentation designed for risk assessment, service engagement and case management of younger adults. Sometimes this focus and attention is justified with older adults, but this is rarely the case. Case files end up with pages of redundant white-space, white noise that slows what we might call conventional information retrieval.

It has been recognised for a long time that IT systems are key to unlocking multidisciplinary working and joining the dots of policy across health, social care and associated care sectors. The outcome of the CPA review is due later this month, it will be very interesting to see the direction this takes and what hooks there are for Hodges' model. The hooks I can see and well and truly intend to snag my lip upon here include:

• "paperless working";
• self-assessment;
• e-working at the point of care;
• collaborative working and treatment with education interventions;
• individual budgets and new commissioning models;
• social inclusion, social enterprise;
• social capital and employment.

Ultimately, I do believe Hodges' model will find its niche - why? Clearly, the 4P's with records and policy in particular are becoming ever more complex. At times like this a tool to -

simplify and summarise : engage and educate

- must have a place in our curricula, paper and e-record systems, client's and carer's hands and our cognitive tool sets.

Ack: links Care Services Improvement Partnership.

Health Career Model Cygnet Hospital Bierley [II]

Dear Denise

Thanks for your message, interest and ongoing support of Hodges' model. I've copied your query to Brian. It is marvellous to read of your career to date and how you have adapted the model to fit your needs.

I have some insight into PSI (psychosocial intervention) and feel that the model could certainly be used in your new post. I suppose (as ever) there are several caveats as you may have already found...

Chief among them is that your colleagues may be reluctant to follow your lead - asking for the evidence* to support safe and effective clinical use of Hodges' model?

The website and blog represent a call for research in Hodges model and similar approaches.

In support of Hodges' model in Bierley -

* 16 bed Acute Ward(male)
* 15 bed Complex Needs Ward (male)
* 15 bed PICU Ward (male)
* 15 bed Personality Disorder Service Ward (female)

- as you will be aware the model is very high-level and it does not dictate practice or philosophy. If adopted however the model can help assure (not guarantee) a holistic approach, as you have already found.

You may care to look at the current processes - care pathways - and map these using Hodges' model. Then look at the specifics of therapeutic modality and PSI (for example, specialised cognitive therapeutic/schema therapies personality disorder) on the unit and effects on the key (h2cm) elements -

INDIVIDUAL-GROUP
HUMANISTIC-MECHANISTIC

- and across the four knowledge domains.

On the blog, check the post 'labels' (on the right-hand side) for -

process,
practice,
purpose
and policy [4P's]. These posts may help also.

An often 'neglected' area is outcomes and outputs. Check what aspects of care (and outcomes) the commissioners of care are focusing upon? Public involvement, client and family engagement may be challenging aspects of care for you and your colleagues? You can also utilise the POLITICAL domain which in your work - as with the TEMSS/secure services posts is no doubt central. The focus on PSI is another crucial dimension SOCIOLOGY - POLITICAL, especially if family oriented? What areas do you want change? Should you concentrate your efforts on one care (knowledge) domain, or are there some inter-domain dependencies highlighted in the literature*?

What data do you have on your patient (referral) population (month-year?); your local (catchment area) population?

Hodges' model is a space - what can you fill it with?

What data do you already have? Sometimes this can come as a pleasant surprise, or a data-poverty shock? Who can you speak to internally - externally? Statistics, reports, intelligence? Is your organisation a learning organisation? (There are times to join in with the fashion game...) If so, does that include the clients and their families? Is anyone on a course and in need of a project? What does multidisciplinary team and integrated care (really) mean in your service? Has a staff member been away for 6-12 months, if so speak to them...

Your bed numbers:staffing ratios speak volumes to some people more than others (£...$) how does economics figure across Hodges' model? If it may help SWOT each domain?

Currently on the psychiatric nursing mail list there is a discussion on 'recovery' and employment-benefits. What does this mean for your care objectives and service overall?

If you still have any contacts at Kemple View or notes (essays) that you could possibly share please let me know. If you are interested in writing / collaborating on a paper I'd be happy to assist.

If there is a 'clinical development (governance) lead' in your new organisation it would help to get them on-board - then you are not out-on-a-limb. Your success thus far suggests you'll have this covered!

If you would like some views on your progress to date do not hesitate to tap my screen.

All the best to you and your colleagues Denise with your plans and for the holidays - 2008!

Keep in touch...

Peter J.
===========================================================
Peter,
Thanks very much for your speedy response, I have already met with my two charge nurses on the ward and we have agreed a way forward. There is of course much to do to ensure that we can introduce the model successfully, your answer will prove very useful. I would be happy to keep in touch and of course feel free to add my question to the blog if you think that this will be helpful to others.

Kind Regards
Denise Banks

Health Career Model Cygnet Hospital Bierley [I]

Dear Brian,

I have always been interested in the theory behind the use of Hodges' Health Career Model. During my time as a student nurse (back in 93-96) I came across information about how the HCM could be implemented in practice. As a newly qualified nurse I took these ideas into my first development post at Kemple View in Blackburn, Lancashire and successfully introduced an adaptation of the model adding risk to the dimensions.

I understand that the model is still in use and many patients have benefited from its holistic approach to psychiatric care. I also note reference to this on your web page. I am quite pleased that a student nurse has clearly recognised the benefits as I did during training.I am now working at Cygnet Hospitals at Bierley in Yorkshire and am again looking to introduce the model as a means to provide a framework to nursing care. The favoured approach on the ward (FAIRFAX Rehab - complex care for males) is PSI, but I am of the opinion that the HCM can be used as a framework for nurses to deliver such an approach.I would be interested to know what your thoughts are on this and of course if there is any advice that you can offer.

Many Thanks

Denise Banks RMN PGCM DMS JP

In December 2003 a student nurse brought information to my attention that Kemple View Psychiatric Services, Blackburn, UK are using the Health Career Model as an aid to assessing individual needs.

Links by PJ and reply to follow ....