Severe Mental Illness (SMI) Outreach SDF Funding Plan in Northamptonshire

NHS Northamptonshire Integrated Care Board (ICB) have awarded services under a Pilot arrangement for a period of 12months as part of the Severe Mental Illness (SMI) Outreach model. This contract is awarded as a grant agreement.

The SMI Outreach model includes the following:

• oA dedicated team, comprising physical health nurses, smoking cessation advisors and health & wellbeing coaches.
• oEngaging with GP practices to identify the top 20% of non-responding SMI patients (this equates to c.960 SMI patients in Northamptonshire, per year).
• oMobile testing equipment to allow a comprehensive physical health check in any location across the system.
• oSmoking cessation advice, where applicable, including awareness-raising around smoking risks for SMI patients and access to Nicotine Replacement Therapies or local authority smoking cessation services.
• oAdapted de-briefing sessions to explain the result of the health check including lifestyle and behaviour recommendations.
• oUp to 6-week health and wellbeing coaching delivered by Peer Support Worker - to include community navigation, resolve access barriers and support new habit formation.

The provider will support:

• oformation and mobilisation of a peripatetic team, including a clinical/ non-clinical skill mix that support the delivery of a comprehensive physical health check
• osupport relationships with GP practices in Northamptonshire or the East Midlands region
• owork closely with Primary Care to ensure the Ardens SMI Health Check template is completed (in full) on both System 1 and EMIS clinical records, and in a way that ensure the health check is visibly completed on the Ardens Manager Platform
• omobilise equipment and facilities to deliver all aspects of the health check across a range of community locations, including within the patient's home.
• oenable access to dedicated awareness-raising, advice, guidance and support for smoking cessation.
• oenable access to focused debriefing, in which patients who receive a health check can be given opportunities to discuss the outcomes, clarify their understanding, and fully comprehend the recommendations for follow-up intervention.
• oenable access to person-centred, needs-led guided support and intervention to bring about lifestyle and behaviour change
• owork within the financial envelope of £202,000 per annum