INTRODUCTION

This chapter considers community mental health teams for older people. It examines their composition and function. In those places with universal health systems, such as Australia, New Zealand and the United Kingdom, assessment and care of older people with mental health problems is usually carried out by community-based multidisciplinary teams. In urban centres, there are often multidisciplinary teams devoted to the care of older people. As the scientific literature on this topic is sparse, this chapter is based mainly on our own experiences over many years working in dedicated community mental health teams for older people.

TEAM SIZE

Community mental health teams for older people usually consist of 6 to 12 health workers, together with one or more administrative personnel. Smaller teams can be more difficult to sustain, as members are often the only representatives of their professional groups, there is less intraprofessional support available and it is difficult to arrange leave cover. Larger teams are usually broken into subunits because when teams have greater than 12 members their team meetings become lengthy and difficult to manage. Teams with 6 to 12 members can tolerate periods of absence for sick leave, recreation leave and parental leave without an unacceptable load falling to other team members.

TEAM COMPOSITION

The core professions needed by a community mental health team for older people include medicine, nursing, social work, occupational therapy and psychology. There are advantages in also having input from pharmacy, speech pathology, dietetics and physiotherapy, although such personnel are likely to be used solely for their profession-specific knowledge and skills, rather than for generic mental health tasks, such as initial assessment and case management. Even with the advent of mobile communications technology, community teams cannot work well without competent support from administrative personnel.

LEADERSHIP

In many places, including Australia, there are statutory requirements for people to be admitted to mental health services, including community mental health teams, under a specialist psychiatrist. As a result, in many community mental health teams for older people, a psychiatrist is likely to have ultimate clinical decision-making responsibility. The local Mental Health Act is also likely to require a psychiatrist to take responsibility for people managed under its involuntary treatment provisions. Depending upon the psychiatrist’s personality and inclination, the psychiatrist might also take on service development and innovation roles.

There is another leadership role needed in all but the smallest community mental health teams. Team leaders, often drawn from the ranks of senior nurses, have important administrative responsibilities as teams grow beyond about six members.

TEAMWORK

Teamwork often comes naturally to people attracted to working in community mental health teams for older people. The specific knowledge and skills of the various health professions are essential to the day-to-day work of such teams. Thus, there are plenty of opportunities for health workers to practise their own professions, as well as more generic mental health worker roles such as case management. As a result, personnel are more likely to derive satisfaction from their working lives and staff turnover is often quite low.

Sometimes, however, personnel are drafted in from adult mental health teams and do not have a strong inclination towards working with older people. In such circumstances, it will be incumbent upon existing members of the team to introduce the new worker to the quite different philosophy of the community mental health team for older people. It is often invaluable for new workers to work alongside enthusiastic and experienced workers to gain familiarity with the work style and philosophy.

WORKLOAD

Clinicians working in community mental health teams for older people can expect to be busy. Typical tasks include individual counselling and behaviour therapy, family meetings, and liaison work with general practitioners, community health workers and residential aged care facilities. They will need to work with local retail pharmacies to provide people with medication-dispensing systems. They will need to assist people to access local health and welfare services, as well as income maintenance and accommodation services. They will need to negotiate through the various parts of the local Mental Health Act. They may need to transport people to various appointments, including the local pathology provider to have blood tests done.

Caseload allocations are likely to be based on the number of cases, case complexity and local issues, including sociodemographic factors, living arrangements, geographic location and traffic patterns. The work model adopted by the team might also influence workload allocation.

GENERIC CLINICAL ROLES

Despite ample opportunities to practise specific professional roles in most community mental health teams for older people, there are generic clinical roles that most members of such teams will need to gain familiarity with. All team members will need to be competent at doing initial clinical assessments, including mental state examinations, and all team members will need to understand case management as it is applied to older people with mental health problems. Teams vary in the extent to which they mix the application of generic and profession-specific roles. However, as a broad generalisation, mental health teams for older people probably use profession-specific skills more frequently than adult mental health teams.

THE VALUE OF DIFFERENT PERSONALITY TYPES

In his excellent book on community mental health teams, Burns (2004, pp 23–24) recommends a mix of personality types in a community mental health team. He recognises that ‘a core of unflappable staff’ is necessary for people to feel ‘contained and safe’. But he also indicates that it is useful to have personnel who ‘thrive on crises or who can communicate excitement and enthusiasm’.

THREATS TO TEAM COHESION

There are some common threats to team cohesion. These include lack of agreed roles for team members, lack of clear reporting structures and lines of responsibility, inequitable workload distribution, and lack of adequate professional supervision. It is essential that team members understand the balance between generic case management roles and profession-specific roles that they are required to undertake. This may sometimes require careful negotiation between the worker and the team leader, and is best established at the beginning of employment with the team. Effective teams need effective team leaders, and personnel need to be quite clear about lines of clinical responsibility. The local Mental Health Act will define some of these responsibilities, and team protocols need to take these requirements into consideration. The team leader must meet very regularly with team members so that issues can be identified and resolved at the earliest opportunity.

Perceptions of inequitable workload distribution are common sources of dissatisfaction within mental health teams. Distribution of workload should generally be on a numerical basis—that is, each worker should be allocated approximately the same number of older people. Some consideration needs to be made for case complexity, although much mental health work with older people involves considerable complexity. Professional supervision is critical to professional development and risk management, and is dealt with in more detail below.

Some conflict is inevitable, even in well-functioning teams. In itself, conflict is not necessarily a bad thing, as it often precipitates an examination of a practice. However, conflict that does not have a forum or is not allowed to surface is likely to fester and could destabilise a team. Mental healthcare in the community is difficult enough without destructive forces within a team using up everyone’s emotional energy.

TOLERANCE AND HUMOUR

In any community mental health team for older people, there is likely to be a mix of personality styles and a mix of motivations for working in this challenging field. Sometimes, these differences will cause friction among team members. Tolerance is an essential ingredient for working with the mentally ill and an essential ingredient for working in a well-functioning team. Humour is often useful in defusing a difficult situation that has arisen within a team, although it does take some time to know just how far to take certain types of humour.