HSE launches a new model of care for people with severe and enduring mental illness


Recognising that a small but significant number of individuals with severe and enduring mental illness are repeatedly admitted to acute inpatient units where many remain for lengthy periods, the HSE Mental Health Services Team initiated a national project to develop a revised care approach. Through enhancement of rehabilitation and recovery services, the aim is to give people the hope and necessary skills to enable them to exit long-term care to live a rich and  independent life within their own community.

CES and HSE Collaboration

The Community Operations Improvement Programme is an ambitious undertaking involving new ways of working to improve health services. CES is working alongside the HSE to support its development and implementation while building long-term capacity to deliver change and improve services. Through the Community Operations Improvement programme, CES partnered with the HSE to plan and implement this project.

Model of Care

The project team comprising clinical and operational specialists, representatives from across the mental health services (Psychiatry, Psychology, Social Work, Occupational Therapy and Nursing) and a Service User Advocate developed a detailed Model of Care (Model of Care for People with Severe and Enduring Mental Illness and Complex Needs) to describe the rehabilitation care pathway which in turn guides the delivery of the services.

Two National Specialised Rehabilitation Units (SRUs) were commissioned to deliver the service. These SRUs are designed as inpatient centres providing 24-hour care where service users are supported by a multi-disciplinary team through a rehabilitation and recovery focused programme. The creation of a national SRU referral process assures that service users with the greatest clinical need will be prioritised.

CES supported this team through use of project management tools and techniques including process mapping, active risk management and scenario modelling to validate the Model of Care, establish the SRUs and assure full integration of the complete care team.

Where are we now?

On 25th September 2019, the CES and HSE team joined the Minister of State for Mental Health and Older People, Mr. Jim Daly, TD, for the formal launch of the service. The project team have transferred the day-to-day programme operations and oversight to the HSE. The two SRUs are completely operational at full bed capacity. The first service users have successfully followed this care pathway, and through interventions within the SRU have returned to their community where they are living independently.  

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