Safety and Escalation Planning in Community Mental Health Support

Each article in this series has concluded with the same quiet dependency, one from the support worker in the client's home or community, seeing something and the seeing something being significant only if the seeing travels. In mental health support there is no greater need for dependency and the design is often the thinnest. Workers spend more time with clients than any clinician, at the times when things change, and most arrangements leave them with nothing more than a 'raise any concerns' instruction, which is like a hope being a plan.

This is seen in two symmetrical failures, the first being that nobody took action once the worker is not sure if this is a crisis, and the second being the worker is left alone with a crisis that nobody has written down what to do when it happens at 8pm, Saturday. These are design failures, and the design is the practitioner's to write.

The frame: observation travels, judgement stays

The architecture is the same as the Support Network series that the wider network has developed for nursing and behaviour support, but adapted for mental health. The practitioner writes observations and workers observe and report against the frame but clinical judgement about the meaning of the observations remains clinical. The mental health tuning is in the content of the frame; for this person, the early-warning signs in plain observational language, sleep pattern changes, meals stopping, the flat closing in, contact narrowing, etc., are all a part of what the practitioner knows about this person's cycles, and, where applicable, what the person says or does when they're drifting, because the person is often the best cartographer of his or her own early-warning signs, and a frame built with the client is also one the client has consented to.

The three lanes, written down

One page, three lanes to create a workable escalation plan. The routine lane: things they'll observe to record, where they'll record, and who's going to read them on what rhythm, so there's slow drift somewhere that a clinician has to be looking. The prompt lane: the changes that warrant contact today, with a named person, a real number and an expected response time, because a concern that goes to a voicemail nobody checks is not brought to them. The crisis lane: who to call, in what order, which emergency services to call, what to say to the person, calm and non-judgemental, staying-with language, and what not to attempt, a support worker is not the clinician of last resort and the plan should state this in words. If the person has his or her own safety plan, the worker's lane structure dovetails in with it, rather than creating a duplicate safety plan, and the worker is aware of the existence of the safety plan at the level the person has agreed to share.

Build the culture that keeps the lanes open

The lanes fall apart before the structure; the cultural surroundings are the practitioner's to shape. Over-reporting is rewarded: if a call proves to be a false alarm, then the system is functioning correctly, and the first worker who receives irritation for a benign report adjusts the entire setup to silence. The worker who didn't learn anything from his observation does not report it out loud anymore: the loop closing habit, a line back, gets appropriately bounded by the client's confidentiality, and the sensing lives on. And the worker's own load is on the table: mental health support means taking the difficult days; arrangements to have access to debriefing, a named contact after a difficult shift, the explicit permission to say a shift was tough, keeping workers regulated, retaining them and keeping them safe, that's not generosity, that's the maintenance schedule of the instrument the whole system relies on.

How this plays out in practice

Imagine a client who has bipolar disorder whose escalations have been coming at a rapid pace historically, and who's been supported four mornings a week by a worker that has been hired in this series. One-page plan is written by practitioner and client; routine lane is logged by the community team twice a week on a shared note; the prompt lane is the practitioner's duty line; the crisis lane is one paragraph that she helped write. The worker takes the prompt lane on a Thursday in month 4, two nights of no sleep, a grand business plan, routine lost. The duty clinician sees her Friday, the medication adjustment is made over the weekend, and instead of the fortnight admission that ended her last three escalations, it's an outpatient fortnight. The worker didn't do anything clinical. She did one page's worth of the correct thing.

Next steps

This fortnight, write the one-page plan for the highest risk supported client on your caseload, with the client (where possible): three lanes, real names, real numbers, and the crisis paragraph. Then brief the workers, and repeat the sentence that keeps it alive: a call about nothing is the system working.