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Community care (CCU) and extended care (SECU) units - February 2007

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• Purpose
• Key Message
• Background and context
• Community care units
• Secure extended care units
• System interfaces
• Workforce implications

Purpose

The purpose of this program management circular is to clarify the role and function of community care (CCU) and secure extended care (SECU) units. This information should be interpreted within the context of the policy guideline Victoria’s mental health service: the framework for service delivery that describes a continuum of public mental health services for people with serious mental illnesses. Area mental health services should review their local service models, policies and procedures for consistency with the service requirements defined in this circular.

Key Message

CCUs and SECUs form part of the continuum of specialist clinical mental health services and are staffed by multidisciplinary clinical teams. CCUs provide 24-hour clinical care and residential rehabilitation to people with severe mental illness and associated disability who are unable to be supported in available less intensive community options. SECUs provide secure inpatient treatment and care for people with severe symptomatology and associated behavioural disturbance who require an extended period of sustained treatment and rehabilitation in a contained environment.

Background and context

Community care and secure extended care units have been operating since 1996. Their service specifications, role and function within the broader mental health service system were defined in a series of policy documents including the Victoria’s mental health service: the framework for service delivery (1998). Over time, the mental health service system has developed and expanded to improve the options available to individuals requiring treatment and support within a rehabilitation and recovery framework. A wider range of supported residential services have been introduced in partnership with the psychiatric disability and rehabilitation
support sector.

In this context services have developed local models and rehabilitation programs for their CCUs and SECUs to meet the needs of people within their catchment area, or relevant region. It is important that the focus and function of these services remains aligned with their intended role within the broader mental health service system so that consumers have access to the full continuum of available services according to their need.

This circular restates the key functions of CCUs and SECUs, their target groups, admission and discharge requirements and links with other service components and sectors.

Community care units

Key functions
Community care units provide medium to long-term accommodation, clinical care and rehabilitation services for people with serious mental illness and associated psychosocial disability. Located in residential areas, CCUs provide a ‘home like’ environment where people can learn or re-learn everyday skills necessary for successful community living.

CCUs provide:

• medium to long-term clinical and rehabilitation support for people who are unable to live in other community residential options
• access to 24-hour multidisciplinary clinical support and treatment, including regular medical psychiatric review
• residential rehabilitation programs according to client need
• individualised assessment, care planning and review of suitability for less restrictive treatment and care
• psycho-education and support to carers and promotion of continued links between consumers and their carers
• monitoring, engagement and support of people receiving involuntary treatment under the provisions of the Mental Health Act 1986
• promotion of community links and partnerships to foster consumer integration into the broader community.

Target group

CCUs are targeted at people with severe mental illness or disorder and associated disability who require 24-hour clinical support in a community environment. Typically residents will have significant symptomatology that may be slow to respond to treatment or experience behavioural disturbances that make living in alternative community settings difficult.

While it is envisaged that people will move through the units to other community residential options, some consumers will require this level of support and supervision for a number of years. CCUs are required to provide a range of programs aimed at the consumer’s clinical treatment and rehabilitation needs. Some consumers will benefit from a period of intensive rehabilitation before moving to more independent living. Others may require a highly supervised supported environment for an extended period to assist in managing their problematic behaviours. People should not be excluded from a CCU based on a lack of willingness to participate in the program or perceived lack of rehabilitation potential.

While the preferences of consumers and their carers should be taken into account when considering admission to a CCU, such units must have the capacity to engage, contain and support involuntary patients.

Admission to CCU

Area mental health services should maintain appropriate referral and assessment processes for considering referrals, monitoring waiting lists, assessing available community options and facilitating smooth transition between service elements. Clear admission criteria for the CCU should be developed that reflect their intended role and function and ensure:

• people with the greatest need for CCU care receive the highest priority for admission
• the preferences of consumers and their carers are considered as part of the admission process
• the CCU is able to provide safe and therapeutic care
• limitations in achieving functional gain through residential rehabilitation programs are not used to restrict access to the CCU.

Discharge from CCU

Discharge will usually be based on the individual’s capacity to live in an alternative community environment. Area mental health services should work with psychiatric disability rehabilitation and support services (PDRSS) to develop discharge processes that ensure people leaving the CCU have appropriate accommodation and access to ongoing mental health treatment and support. Policies should encourage early discharge as appropriate and facilitate links and partnerships with other community, housing and support providers. Transitional arrangements may be necessary to ensure successful discharge to new accommodation and support the individual in settling into their new environment. Admissions to an acute inpatient unit for short-term treatment should not automatically result in discharge from a CCU.

Secure extended care units

Key functions

SECUs provide medium to long-term inpatient treatment and rehabilitation for people who have unremitting and severe symptoms of mental illness or disorder with an associated significant disturbance in behaviour that preclude their living in a less restricted environment. These services are provided on a regional basis, and are gazetted under the Mental Health Act to provide involuntary treatment. SECUs represent the highest level of care on the continuum of mental health services and provide extended clinical treatment, supervision and support for those whose needs cannot be met adequately by other available programs and services.

SECUs provide:

• contemporary, high-quality, multidisciplinary secure extended inpatient treatment services, including regular medical psychiatric review
• capacity to contain people with severe symptoms and behavioural disturbance in a safe and therapeutic environment
• individualised assessment, care planning and review of suitability for less restrictive treatment and care
• targeted treatment and rehabilitation programs that maximise individual functioning, minimise the ill effects of long term care, and promote return to community living where possible
• behaviour management programs to modify disruptive behaviours and maximise social and personal functioning
• education and support to carers and encouragement of continued links between consumers and their carers, and the community
• links with other service providers, especially referring services, and elements of the service system to promote continuity of care and ensure effective admission and timely discharge.

Target group

SECUs provide secure and extended inpatient care for people with unremitting and severe symptoms of mental illness or disorder and associated behaviour disturbance who meet criteria for involuntary admission. As the most restrictive treatment setting, SECUs are intended to target people with the most difficult and serious disturbance who are unable to be safely or adequately treated in less restrictive settings. Typically SECU residents are a high risk of harm to themselves or others and frequently have comorbid conditions including drug and alcohol problems, acquired brain injury or intellectual disability.

It is envisaged that SECUs will provide treatment and care of clients who are able to benefit from the unit’s program and progress to other components of the service system in a relatively short period, and the extended care of clients whose level of disturbance or disability prevents their moving on to alternative settings in the foreseeable future.

Admission to SECU

Area mental health services should maintain appropriate referral and assessment processes for considering referrals, monitoring waiting lists, and facilitating smooth transition between service elements. Clear admission criteria for the SECU should be developed that reflect their intended role and function and ensure:

• people with the greatest need for SECU receive the highest priority
• the preferences of consumers and their carers are considered as part of the admission process
• the presence of a comorbid condition or perceived
  rehabilitation potential does not restrict access to SECU.

Discharge from SECU

Area mental health services should work with PDRSS and develop discharge policies that ensure people are discharged to appropriate accommodation and have access to ongoing mental health treatment and support. Transitional arrangements may be necessary to ensure successful discharge, or a trial discharge in a less restrictive setting.

System interfaces

CCUs and SECUs are core components of an area mental health service (AMHS). SECUs are delivered on a regional catchment basis, and services need to have active links with the referring area mental health services. Appropriate administrative and clinical governance arrangements should be in place for the agencies providing services as well as those of AMHSs accessing SECUs in other areas. Protocols should be established between AMHSs and their relevant SECU defining clear points of accountability for both service and client management. The authorised psychiatrist of the auspicing health service has overall responsibility for the quality of care delivered within the units.

CCUs and SECUs form part of the broader specialist mental health service sector that includes PDRSS and strong working relationships should be maintained with relevant PDRSS providers.

Collaborative relationships should be in place with a wide range of local providers including general practitioners, community health services and housing providers to meet the multiple needs of the client group and facilitate community re-integration.

Workforce implications

The effectiveness of CCUs and SECUs is dependent upon an adequate number of appropriately trained clinical staff. The complexity of consumer needs and the challenges associated with working in environments where client progress is slow or minimal provides a risk of burnout and attracting and maintaining staff can be difficult. Full multidisciplinary participation in the staffing team is required as well as sufficient attention to continuing education programs, clinical supervision and other appropriate staff support mechanisms.

CCUs and SECUs should implement evidence-based recruitment and retention strategies such as providing clinical placements for undergraduate students, ensuring entry-level positions, encouraging rotations through the unit from staff from other areas and supporting education, clinical supervision and research opportunities.