Assertive outreach teams

This page explains what an assertive outreach team does. And when you might be referred to them. You may also find this factsheet useful if you care for someone with a mental illness.

Overview

  • Assertive outreach teams (AOTs) are specialist mental health teams.
  • AOTs may also be called complex care teams (CCTs).
  • They are made up of mental health specialists to support your needs.
  • You may be with the assertive outreach team if you have severe mental illness and you find it difficult to work with community mental health teams (CMHTs).
  • You may be with the AOT if you have recently been discharged from hospital.
  • AOTs will only accept referrals from your CMHT. Your GP can’t usually refer you.
  • Not all NHS trusts will have an AOT. Your CMHT should be able to arrange the support you need.

 

What are assertive outreach teams (AOTs)?

Assertive outreach teams (AOTs) are specialist mental health services. They may be part of the community mental health team (CMHT), or they might be a separate team. They work with people who are over 18 years old who have ongoing complex mental health needs. And need intensive support because of mental disability.  In your area, the NHS might call their AOT a complex care team (CCT).


You may need the team if you have:

  • a severe long term mental illness that affects you every day,
  • been in hospital many times and have often used crisis services,
  • problems working with mental health services, or
  • complex needs such as:
    • violent behaviour,
    • serious self harming,
    • not responding to treatment,
    • drug or alcohol use and mental illness. This is known as dual diagnosis, or
    • unstable accommodation or are homeless.

The AOT provide intensive support if you have complex needs. The team aim to support you to get help from other services. This support can help you to manage your condition better. And reduce your chances of going back to hospital.

The support you may get from an AOT might be the following.

  • Help with daily living such as shopping, budgeting, cooking and cleaning.
  • Help with your medication.
  • Talking therapies.
  • Help with drug or alcohol use.
  • Support to be involved in community if you are isolated.
  • Help to improve your physical health.
  • Support to find suitable education, employment and training.
  • Support to find and keep your home.
  • Make a plan with you to help you manage your condition. This will look at things that can make you unwell.
  • Make a crisis plan with you. This is a step by step guide of what you need to do if you start to become unwell.
  • Support for your carers or family such as learning about your condition and family behavioural therapy.

AOTs try to have most of their appointments in the community or the home. You can work with your AOT to decide on a place you feel comfortable.

All mental health teams should make a care plan for you and review it regularly. AOTs should do the same and review it around every 6 months.

Who is in an assertive outreach team?

Assertive outreach teams have staff from different backgrounds. Most staff will have health or social care backgrounds. There will usually be psychiatrists, social workers, community psychiatric nurses, psychologists and occupational therapists.

Psychiatrists
A psychiatrist is a specialist mental health doctor. They can diagnose mental illness, prescribe medication and recommend treatment.

Social workers
A social worker is trained to give practical help with your social needs. This might be help with housing problems, financial issues or giving general support.

Community psychiatric nurses (CPNs)
A CPN is a mental health nurse who works in the community. They can support you with taking medication, manage your health and offer you treatment in the community.

Psychologists
A psychologist specialises in how people think and behave. They are not usually medically trained.

Occupational therapists
An occupational therapist can help you overcome difficulties with everyday tasks. They support you to be independent.

Other professionals
Other people will also be in the team such as managers, psychotherapists and administrators.

All the staff work together and meet to discuss your progress. These are called ‘multi-disciplinary meetings’.

How can I access the assertive outreach team?

A health professional will need to refer you to an assertive outreach team (AOT). If the AOT accept the referral they will book an appointment for you. A referral is when a health professional asks a different service to support you. AOTs take referrals from community mental health teams (CMHTs) and other mental health teams in the community.8,9 AOTs will not usually accept referrals from:

  • your GP,
  • you, or
  • your friends and family.

Assertive outreach teams work with fewer people than the CMHT. This means it can be difficult to get referred to an AOT.

My area doesn’t have an assertive outreach team. What support can I get?

Your CMHT should be able to provide you with the support and care that you need.

You may be able to get further support through:

  • your local authority through a ‘social care assessment,’
  • charities, such as Rethink Mental Illness, and
  • your GP.

You could ask your doctor to make an individual funding request (IFR) if there isn’t an AOT in your area. An IFR means that your NHS trust will decide if they will pay for treatment or a service that you need. Your doctor will only be able to make the referral if they can show that you have a very high need for this type of service.

What happens after I have been referred?

If the team accept your referral they will give you an appointment. You will usually get a letter to confirm the time, date and location of your appointment. But they may ring you. You will be assessed at your first appointment. The assessment may take a few appointments to complete.

What is an assessment?

The AOT will ask you questions to understand what support you need from their team. They will ask you about how you are feeling, and what support you already have. Together, you will decide how to move forward with your treatment and care. At the end of the assessment you should have a care plan in place. The care plan will outline what your needs and preferences are. The AOT care should not just look at what the professionals and services already have. The AOT will support you with your needs. You might be assessed by 1 or more staff members.

Your GP will look after your physical health needs if you are referred to the AOT. Your GP should do a physical health check for you every year if you have a severe mental illness. They should have a register to remind them when your health check is due. People with severe mental illness are at higher risk of developing certain physical health conditions.16 In your health check, a doctor or nurse may check:

  • your blood pressure,
  • your pulse,
  • your urine
  • your blood or
  • weigh you.

 

The Care Programme Approach (CPA)

You may be put under the Care Programme Approach (CPA) if the assertive outreach team think you are a high risk. Or you need support from a number of different services. CPA is a framework of care that it used to organise your care and support.

On the CPA you should get a care plan and a care co-ordinator. Your care co-ordinator will be responsible for your care and support. They should review your plan regularly to check that your needs are being met. A care co-ordinator can be a social worker, community psychiatric nurse (CPN) or occupational therapist.

If you are not under CPA you can still get support from a mental health team.

When will I stop seeing the assertive outreach team?

You should be with the assertive outreach team (AOT) for as long as you need it. The AOT may refer your care to the CMHT if you no longer need intensive support. The team should involve you in the discharge process. You can involve family or carers if you want to.

You will have to be referred back to the AOT if you need the service after you are discharged. But you should get a quick referral.

Problems with my assertive outreach team

You might not be happy with your care or treatment from the assertive outreach team (AOT). Below are some ways you can try and fix any problems.

Your care coordinator
If you have a care coordinator, speak to them about any issues that you have with the AOT.

PALS
Contact your local Patient Advice and Liaison Service (PALS). PALS can try to help you with any problems or questions you have. You can use the website link in the useful contacts section of this factsheet to find your local PALS. Or you can contact the Rethink Mental Illness Advice Service on 0300 5000 927.

Advocacy
You can use a community advocate to help talk to your care coordinator or AOT. They can help to make your voice heard and deal with problems. They may be able to help you write a letter to the NHS. Or go to an appointment with you. Advocates are not part of the NHS and are free to use.

Complain
Make a formal complaint. There will be details on your local trust website about how to make a complaint. An NHS Complaints Advocate can help you with this.

 

What about confidentiality? 

The assertive outreach team need your permission to share information with other professionals or your family or friends.19 They can share information with your GP because they need to be involved in your care.20 They can share information with other professionals if they are worried that you might be a risk to yourself or other people. Or if they are ordered to by a court.

 

 

Information for carers

If your relative agrees, you can be involved in their care. This could include going to appointments with them and giving your opinion about what care they need. Unless your relative agrees, the team can’t share information about them with you or other people.

You should speak to your relative to agree what information they want shared with you. Your relative can then tell the professionals what they want shared. They could write down their consent on a consent form. This could be attached to their medical records.

Your relative will need to have mental capacity when they fill out the form. Mental capacity means someone understands the decision they are making. There is no official consent form. But there is a template consent form that your relative can use at the end of our factsheet, ‘Confidentiality and information sharing’

The Assertive Outreach Team may give you information about relative’s mental illness and how to support them. This is called ‘psycho-education’. The AOT might also offer family counselling if your relatives behaviour is difficult to manage. Ask the staff at the AOT if you need any help.

Help for you
If you need support to care for your relative you could ask for a carer’s assessment. These assessments are done by your local authority. Call your local adult social services to ask for one. A carer’s assessment is free.

It is important to look after your own emotional wellbeing. You can check if there are any local support groups for carers, friends and relatives. Or you can contact the Rethink Mental Illness Advice Service on 0300 5000 927 to find out what services or groups are in your area.

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