The “Community Mental Health Team” (CMHT) is the mainstay of the community mental health system – the “core team” and provides clinical recovery orientated services for people living in the community.
The CMHT’s priority is coordinated care for two groups of people:
1. Some consumers treated by the CMHT will have time limited disorders and be referred back to their GPs after a period of weeks or months (eg after 1–6 contacts) when their condition has improved.
2. Other consumers will remain with the team for ongoing treatment, care and monitoring for prolonged periods 6 months to several years or longer. They will include people needing ongoing specialist care for:
1. Severe and persistent mental disorders associated with significant disability, predominantly psychoses such as schizophrenia and bipolar disorder.
2. Longer term disorders of lesser severity but which are characterised by poor treatment adherence requiring proactive follow up.
3. Any disorder where there is significant risk of self harm or harm to others (e.g. acute depression) or where the level of support required exceeds that which a primary care team could offer.
4. Disorders requiring skilled or intensive treatments (e.g. CBT, vocational rehabilitation, medication maintenance requiring blood tests) not available in primary care.
5. Complex problems of management and engagement such as presented by consumers requiring interventions under the Mental Health Act (2007), except where these have been accepted by other specialist teams.
6. Severe disorders of personality where these can be shown to benefit by continued contact and support except where these have been accepted by an assertive outreach team or a specialised personality disorder team where there is one.
The role of the team includes evidence based active care coordination taking a whole of life approach and ensuring continuity of care to individuals and their families and carers. The role includes re integration into community following inpatient admission.
The model provides rapid response and assessment of mental health crises in the community with the possibility of offering comprehensive acute psychiatric care at home until the crisis is resolved, and usually without hospital admission. Where hospitalisation is necessary, the team has a role in facilitating early discharge. The model is a Recovery oriented approach.
The model provides an extended period of treatment after assessment up until the acute symptoms are resolved or the consumer is effectively transferred and engaged with an appropriate treatment provider.
The service in partnership with the Mental Health Telephone Access Line manages access to mental health care for those in the community experiencing a mental health emergency or who are at risk.
The nurse in the team provides effective, needs-assessed nursing care and services as part of an integrated mental health service. Service delivery will primarily be in the area of assessment, care planning, interventions and liaison with relevant agencies. The position may involve coordinating medication clinic services.