Older Adult Community Mental Health Team (COACH)

This section tells you about the team and the types of services they can offer.

The Older Adult Community Mental Health Team (COACH) is a community based multi-disciplinary team that offers mental health assessment and support to islanders who are generally aged over 65. The team also provides support to people under the age of 65 where dementia is the primary diagnosis.

One particular responsibility of the team involves assessing for dementia, establishing diagnosis, prescribing memory-enhancing medications and providing post-diagnostic follow-up. This happens via the Memory Clinic pathway.

Another focus of the OACMHT is to support people in the community to live with either acute or enduring mental health conditions. The ethos of the team is to promote wellbeing, prevent deterioration, and to help people remain safely at home for as long as possible. In many cases (such as dementia) the condition is not reversible and so the focus is on adaptation and helping families develop strategies to cope. This may involve providing education about dementia and helping carers understand why some difficult behaviours may occur. At times, medication may be recommended in the short-term treatment of mental health conditions and this requires monitoring by team members.

Much of the work that the OACMHT do is focused on helping and supporting carers in their role. The team link closely with the Alzheimer's Society (01481 213367)  michael.nicholls@alzheimers.org.uk and the Guernsey Alzheimer's Association (01481 245121) info@alzheimers.gg in providing this carer education and support. This involves family carers but also carers and managers supporting people with dementia within residential and nursing home settings. Team members also visit Alderney about every three weeks where they run a clinic in the Mignot Memorial Hospital.

The team help devise personalised care plans in conjunction with the service user and family once their needs have been fully assessed. They undertake risk assessments and also identify the strengths that a person possesses. The team can offer advice and signposting towards local services. They can also offer advice around medications and will liaise closely with the person's own GP in this regard.

If a person needs practical help with personal care such as washing and dressing, prompting with medications or shopping the team can liaise and refer to the Community Services team to help put this in place although waiting lists are likely. Unfortunately the OACMHT do not currently have the capacity to offer ongoing follow up to people with dementia unless the issues become complex in nature. This is an area where the growth of the voluntary sector may be able to support Health and Social Care services.

Referral to the OACMHT is usually via the person's own GP. The team contains professionals from various disciplines listed below. 

  • Consultant Psychiatrist:

    • The consultant psychiatrist is the clinical and medical lead of the multi-disciplinary community team and supports the various members of the team in their roles. The consultant ultimately makes decisions regarding the admission and discharge of patients to and from the assessment ward (Tautenay). The consultant psychiatrist maintains medical responsibility and makes clinical decisions about patient's care which includes those in Tautenay ward, the Lighthouse wards and Duchess of Kent. The consultant also devises treatment plans for people seen at home, out-patient clinics or in residential/nursing homes.
    • The consultant undertakes a key role in assessing and admitting patients under the Mental Health Law in association with an approved social worker. The consultant also maintains a liaison role with medical colleagues in the PEH and will offer advice on patients' care where cognitive impairment or functional mental health issues are suspected. They also have a role in advising on the future development of the older adult mental health services.
  • Associate Specialist

    • The sssociate specialist psychiatrist undertakes a similar medical role to the consultant but offers specialist input within the Memory Clinic pathway where they run a weekly diagnostic clinic. The associate specialist also provides regular support to Alderney through clinics held there.
  • Team Manager

    • A community mental health nurse with responsibility for the daily management and development of the team. The manager also sees some patients in a clinical role and has regular involvement with the Memory Clinic and runs clinics in Alderney.
  • Team secretary

    • The team secretary provides an invaluable role in co-ordinating the team members, organising meetings and allocating referrals to individual team members. The secretary is the main point of contact for the OACMHT and can be contacted on 725241 ext 3515
  • Community Psychiatric Nurses (CPN's)

    • Specialist mental health nurses working with people and their families and involved in undertaking first line mental health assessments, cognitive assessments, carer assessments and have responsibility for drawing up care plans and reviewing them. CPN's tend to have involvement with supporting clients with commencement and titration of medication and monitoring effectiveness and concordance.
    • CPN's have a special interest in the Memory Clinic pathway. This early diagnostic pathway involves the completion of detailed assessments of a person's cognitive and functional abilities, their background history, their living situation and the needs of the carer.
    • All of the CPN's have involvement in carer education and some in-reach work into the private sector care homes.
  • Occupational Therapist

    • The occupational therapist (OT) undertakes numerous roles within the team. The OT provides an essential link to the admission ward (Tautenay) and can help facilitate earlier discharge of clients by offering functional assessments of a person's strengths and needs; they are specialists in planning care and support based on the outcomes. 
    • The OT also plays an important role within Memory Clinic and can add their expertise to the assessment process, particularly around safety and risk assessment in the home which may be of concern due to a person's dementia.
    • The OT has been instrumental in developing the carer support groups in conjunction with the Alzheimer's Association and has forged valuable links with the Alzheimer's Society and other voluntary sector groups. The OT has also played an important role in developing the role of the support worker within the team.
    • Further roles of the OT include:
      • Providing non-pharmacological management of symptoms, such as behavioural disturbance and depression.
      • To complete functional assessments to support diagnosis.
      • Assisting home carers to work 'with' rather than 'for' people with dementia, thereby reducing dependence.
      • Effective and efficient discharge planning.
      • Prevention of admission to hospital with effective interventions to manage risk.
      • Ensuring that developments in tele care and assisted housing are appropriate for people with dementia.
      • Providing 'in-reach' services for people in care homes, in order to enable meaningful occupation.
      • Home hazard assessments and adapting or modifying the home environment.
      • Providing advice, support and education to carers.
  • Community support workers

    • The support workers undertake a variety of important roles in supporting people with dementia in the community. This person can provide intensive support to people who live alone and who may need several daily visits for a period of time. They also provide invaluable practical support to people with dementia such as helping with filling in forms, organising equipment and liaising with the handyman service. The support worker liaises closely with the generic community care team to help facilitate seamless handover of care without too much anxiety for the person.
    • They also provide essential transport links for people who would otherwise not be able to attend various groups.
  • Social Worker

    • The OACMHT have in the past had a dedicated social worker in the team. The post has recently been amended to sit within Community Services so that the role will be split between Older Adult Mental Health, community services and one week in four will be assigned to the Duty Social Work Team.
    • Many of the people supported by the OACMHT will require specific social interventions and practical support. Previously the social worker within the Older Adult Mental Health Team supported families to arrange respite, access benefits and advise on long term care placements, and whilst this is important their role is much more complex than this. The absence of a specialist dementia care social worker means that the CPN's and occupational therapists have to be much more involved with organising long term placements for families.
    • Social workers have a crucial part to play in improving mental health outcomes for service users. They bring a distinctive social and rights-based perspective to their work. Their relationship based skills and their focus on personalisation and recovery, can support people to make positive, self-directed change. A specialist social worker also maintains an important link with our adult social work colleagues.
    • Social workers are trained to work in partnership with people who use a range of health and social care services. They involve their families and carers, to optimise involvement and collaborative solutions. They help link services together to provide tighter plans of care and to avoid duplication of work.
    • Social workers also manage some of the most challenging and complex risks for individuals and make decisions with and on behalf of people within complicated legal frameworks, balancing and protecting the rights of different parties. This includes, but is not limited to, their vital role as the core of the Approved Mental Health Professional (AMHP) workforce.
    • A social worker is required to liaise closely with the consultant psychiatrist when planning to admit persons with dementia who present with complex mental health and social needs under Guernsey's Mental Health Law (2010) [69]. The SW can also provide advice on legal matters and will be an essential component in the team with the advent of the incoming Capacity Law.
  • Psychologist

    • The OACMHT do not currently have a dedicated psychologist but can refer people on to such services if psychological interventions (Cognitive Behavioural Therapy, counselling etc.) is required.
    • There is still establishment for the OACMHT to have their own psychologist who the team feel could play an important role in devising behavioural support plans to help educate staff on approaches to care, particularly within the care home sector.
    • Psychologists also play an important role within Memory Clinic services and can deliver specialist psychometric testing and offer detailed analysis of test results.
    • The OACMHT have access to a psychology assistant for some clinic sessions.