HUB Model Programme Framework: Staff

Manual

A guide to support staff in implementing the HUB model in in EVE Services

Glossary of Terms

Active Citizenship

Community Integration

Refers to citizens who become actively involved in the life of their communities. Active Citizenship implies action and empowerment, i.e. acquiring knowledge, skills and attitudes, being able and willing to use them, make decisions, take action individually and collectively with the aim of improving quality of life.

The opportunity to live and actively participate in the community, and be valued for one’s uniqueness and abilities, like everyone else. Community domains can include Employment, Education, Health, Leisure/Recreation, Spirituality, Citizenship, Social Roles, Peer Support, and Self-Determination (Salzer and Baron, 2006).

Decision Supporter

Outreach

Personal Profile

The Decision Support Service uses the term ‘decision supporter’ to refer to a person who has been appointed as a decision-making assistant, co-decision-maker, decision-making representative, attorney or designated healthcare representative. The type of support they can provide depends on the decision support arrangement in place. Ideally, a decision supporter will be a family member or trusted friend.

Outreach is a way of working with an individual and supporting their recovery journey. This can be done with an individual in their own environment. This could be a cafe, a park or in the community – wherever they need it and it helps them most (HSEs Assertive Outreach Model). Each staff member will be the key contact for a number of service users and will contact the service user, or a nominated individual, if the service user is absent for a period of time. (Ref: p. 16)

A Personal Profile is a simple summary of what is important to a person and how they want to be supported. It is written from the perspective of the person. It can be used by the person within EVE services or in other settings if they choose to do so. It is generated using the HSA One Page Profile tool. It can help them get more person-centred support to achieve their goals. A Personal Profile captures all the important information about a person on a single sheet of paper. Personal Profiles are a great way to share a summary under three clear elements: “what others appreciate about me”, “what is important to me” and “how best to support me”.

Person-Centred Plan (PCP)

Person-centred planning may be defined as a way of discovering how a person wants to live their life and what is required to make that possible. Person-centred planning is ‘whole person’-oriented as opposed to disability-management focused. It is about citizenship, inclusion in family, community and the mainstream of life and selfdetermination.

Person-centred planning supports and enables a person to make informed choices about how they want to live their life, now and in the future. It supports the person to identify their dreams, wishes and goals, and what is required to make those possible.

Person-centred planning requires the supports available to be responsive to the person and to focus on the outcomes they want to achieve. It is vital that the entire person-centred planning process is accessible to the person, and that all information provided is in a format that is meaningful to them. (HSE - A National Framework for Person Centred Planning in Services for Persons with a Disability).

Person-Centred Thinking Tools

Peer-led activities

Person-centred thinking tools are a set of easy-to-use templates, devised by Helen Sanderson Associates, that are used to give structure to conversations. Using them is a practical way to capture information that feeds into person-centred planning, as well as to improve understanding, communication and relationships. Examples include, Good Day/Bad Day, Relationship Circle, Important for/ Important to, What’s Working/Not Working etc.

This involves HUB participants in each centre collaborating to identify, develop and implement any initiative (event, outing, group, activity, project) they deem meaningful and worthwhile to themselves, with the support of staff where it is requested. This approach enables us to be more adaptable to participants’ individual needs and encourages self-empowerment through mutual learning and peer support.

Person-Led

Recovery

Acknowledges the autonomy and choice a person has over their decision-making and emphasises informed decision-making and efficacy.

Person-led approaches require that staff and service users focus on the individual, not the service. This means:

• respecting where the individual is at now, their journey, dreams and goals

• matching the services and support with the person’s needs

• working in partnership with the individual, families/ carers to ascertain the person’s capacities and strengths.

Our understanding of the personal and environmental factors that support or impede each person’s unique mental health recovery process has been developing over time. This learning is increasingly influencing how mental health services are being delivered.

Patricia Deegan, a psychologist with lived experience of mental health difficulties, has proposed one influential definition: Recovery refers to the lived or real-life experience of people as they accept and overcome the challenge of the disability… they experience themselves as recovering a new sense of self and of purpose within and beyond the limits of the disability (1988, p.11).

Recovery Action Plan

Recovery Context Inventory (RCI)

Based on the results of the Recovery Context Inventory (RCI), an individual can make a plan to support their recovery through enhancing existing strengths and addressing any areas that they wish to work on. The RCI Recovery Planning workbook provides a guide to creating an RCI Recovery Action Plan.

The Recovery Context Inventory (RCI) has 30 items that were designed to help people to think about key personal and service supports in their life and reflect on:

• how important they are to their wellbeing and recovery

• how often these supports happen

The results will allow the person to think about what is going well in their life and areas they may choose to work on. The RCI Workbook has been developed by HSE EVE to support personal recovery reflection and a Recovery Action Plan.

The RCI was developed to reflect the fact that personal recovery occurs within the context of an individual’s personal life as well as their experience of mental health services.

Trauma-Informed

Universal design

Wellbeing

Wellness Recovery Action Plan (WRAP®)

This means realising that people can be deeply affected by the trauma they may have experienced in life and recognising their need for safe, trustworthy and diverse environments, where they are met with compassion, offered choice, peer support and opportunities to collaborate.

This term describes the effort to create a service which is simultaneously person-centred, recovery-oriented, traumainformed and strengths-based. This approach will make EVE a more accessible, inclusive and progressive service.

Wellbeing exists in two dimensions, subjective and objective. It comprises an individual’s experience of their life as well as a comparison of life circumstances with social norms and values. (WHO, 2012)

WRAP® is an evidence-based practice, consisting of a personalised wellness and crisis plan. WRAP® is underpinned by a a strengthsbased approach to recovery. Participants in the programme develop their own plan to support wellness and recovery based on their own unique experiences and learnings. The key recovery concepts of WRAP® are hope, education, personal responsibility, support and self-advocacy.

Section 1 Setting the Scene

1. Setting the Scene

This document aims to support EVE centre managers and staff to fully understand the HUB concept and guide staff to effectively implement the HUB in their service. It also aims to guide the development of EVE HUB programme specifications and governance.

The HUB Framework document is based on staff and participant feedback postpandemic and aligns with Sharing the Vision (HSE, 2020), particularly recommendation 72, which states: “The current HSE funding provided for day centres should be reconfigured to provide individualised supports for people with mental health difficulties and be consistent with the New Directions policy” (pg. 69).

Considerable efforts have gone into integrating New Directions principles into our HUB services, which is a person-led and aims to be a trauma-informed programme using a universal design approach. As per the EVE Strategic plan 2024-2028, we have recently engaged in a period of academic research and debate, to understand how adopting a trauma-informed approach will work with our current practices. In doing so, we encountered the concept of Universal Design as an approach to healthcare. This requires service providers to develop compassionate, collaborative relationships with members/ participants and respect all forms of diversity, which can be fully achieved in the HUB services via Discovery, person-centred planning, CATCH etc. Our staff training and development programme will both underpin our approach and support staff deliver high quality programmes and services.

Our vision is to build hope-inspiring, compassionate environments with our members & participants, where they feel individually supported to find connection and meaning, to feel empowered and to live the life of their choosing. Which facilitate our members & participants active engagement in the communities where they live, work and learn, in their pursuit of improved health, wellbeing, learning and social inclusion.

The HUB programme will be will be grounded in action that is:

• Hope-inspiring

• Respectful

• Compassionate

• Inclusive

• Empowering

The programme will operate using a hub and spokes model in which the centre will act as a hub to form active and dynamic relationships (spokes) with different community-based services and resources, as depicted overleaf.

HUB & SPOKES MODEL

1. SUPPORTERS

Connecting with families, friends & supporters to enhance connection and partnership working.

2. EMPLOYMENT

Links to help local employers, employability, IPS etc. to support job preperation and readiness.

3. EDUCATION

Links with local community groups, colleges, schools to build partnerships and offer courses onsite and offsite.

4. COMMUNITY

Links with local community groups, and area networks etc. for partnership working opportunities.

5. HEALTH SERVICES

Partnerships with social prescribers, GPs, clinics, Primary Care etc. to support collaborative working opportunities.

The HUB programme seeks to enhance community development, supporting adults who experience mental health difficulties, autistic adults and adults with an intellectual disability to access mainstream services. The ultimate goal is to foster well-being, social inclusion, and personal goal achievement.

The HUB services are person-centred, and participants will be supported to exercise choice and control over the supports and services they receive and build their capability to be self-directing, making informed decisions in their lives in line with Assisted Decision-Making (ADM) and using a human rights-based approach.

Introduction to the HUB Programme

HUB Elements

DISCOVERY PHASE

An individual will start the Programme & work through a Discovery phase where the individual and staff get to know one another. An initial Personal Profile will be developed.

TRANSITION PLANNING

The individual will be supported to think about their plans for the future throughout their programme. This process starts when they walk in the door. It is informed via key worker meetings & Person-Centred Plans. The last six months is dedicated to working on an agreed progression/exit plan.

LIFE SKILLS / ACTIVATION

A tailored programme will be designed for the individual to develop key life skills (for example, cooking, budgeting, work skills). These will be based on their PersonCentred Plan. This is updated via feedback, key worker meetings and updated PCPs/ goals. Can be offered on site, off site or a blend of both.

COMMUNITY MAPPING CATCH

Working with other participants, the individual will identify what is in the community, what supports can be offered to whom, by whom and when.

PATH

Co-produced & peerled group work to meet identified need, e.g. young adult groups, cinema clubs, men’s sheds etc.

LINK

Individuals can link back into the centre in a number of ways. e.g. Dedicated short courses or for LINK sessions.

2. Introduction to HUB

What it is:

The HUB programme is informed by the fundamental belief in the potential of every individual to change and grow and focuses on the individual’s strengths and abilities rather than their deficits.

The assessment of those skills and abilities and the majority of the work undertaken on relearning old skills and developing new ones occur in the settings of everyday life, i.e. the community, homelike setting (ILS Room) etc.

The HUB programme is about is about using curiosity to ask ourselves, ‘If I tried this, if I learnt that, what might I be able to do?’. This curiosity builds hope and provides a basis for connecting with one’s own dreams and goals, and with family and community.

The HUB is comprised of a number of key elements:

• Discovery

An individual will start the programme & work through a Discovery phase where the individual and staff get to know one another. An initial Personal Profile will be developed.

• Transition Planning

This process starts when the individual walks in the door. It is informed via key worker meetings & Person-Centred Plans. The last six months is dedicated to working on an agreed progression/exit plan.

• Life Skills

Tailored programme is matched to the individual based on their Person-Centred Plan. This is updated via feedback, key worker meetings and updated PCPs / goals. Can be offered on site, off site or a blend of both.

• CATCH

Identifying what is in the community, what supports can be offered to whom, by whom and when.

• PATH

Co-produced & peer-led group work to meet identified need, e.g. young adult groups, cinema clubs, men’s sheds stainability & green teams etc.

• LINK

Individuals can link back into the centre in a number of ways, e.g. dedicated short courses or for LINK sessions via CATCH.

How it is delivered:

The HUB programme is delivered through a range of individual and/or group activities that respond to the needs and goals of individual participants. Activities may focus on the acquisition of knowledge in relation

to the HUB’s modules1, i.e. Discovery, Life Skills, LINK, CATCH, Outreach/In Reach Support, PATH; Hybrid programming, peer support; and exploration of oneself and maintaining health & wellbeing through creative pursuits.

Individualised Support:

Because everyone’s journey is different, there is no ‘one size fits all’ solution. The HUB model is person-led using personcentred thinking tools. It takes account of the individual’s needs and works with the individual to plan and achieve their individual goals. A person-led approach focuses on the individual, not the service. This means:

• respecting where the individual is at now, their journey, dreams and goals.

• matching the services and support with the person’s needs.

• working in partnership with the individual, their family/supporters to support them in achieving meaningful personal goals.

The Support it Offers:

The HUB model offers a wide range of supports to improve the individual’s wellbeing, from advice and planning to practical support with daily living skills. It can support the individual with:

• budgeting & financial planning

• transition planning

• behavioural & emotional supports via Slánú

• co-ordination of external support needs, e.g. housing assistance, educational support etc.

• support for daily living

• budgeting assistance

• leisure & recreational

• community participation

• healthy lifestyle planning

1 Ref: Module outlines from page 21 to 43.

• social skills development

• coaching & mentoring

• peer-support

• individual or group-based activities

• employment, training & education

• development of a Recovery Action Plan using the Recovery Context Inventory (RCI)

Offering Choice:

The HUB model supports choice and control for all service users. It ensures that all an individual’s needs and goals are unique and recognises that the individual is an expert in their own wellbeing. This approach will securely place them at the centre of the service they receive and be supported across all areas of their lives into their communities, where the objective is to empower individuals to realise their goals and ambitions. The programme outline will be determined by the needs of the participants…their service, their way!

A Person-Led Approach:

Person-centred, confidence-building and a ‘fun’ social aspect to programme development are essential to the success or failure of a programme. Participants in any group need to want to participate in a programme; this can be achieved by innovative programme development and paying attention to the voice of each member in the group.

Skills Development:

The other aspect to programme development will concentrate on developing the skills of individuals in the group so that they can participate in their communities, to the extent that they wish to do so. Links with mainstream agencies/programmes/activities will encourage participation in services and refine delivery of existing programmes.

Community Integration:

Community integration will be a key component of this programme. The HUB stresses getting participants out into the community to complete meaningful, life enhancing activities. The amount of time spent in the community should be monitored. The goal is to support service users to spend more time in the community the longer they access the programme, dependent on individual needs and abilities. The programme will provide opportunities for community activities and centre-based activities. Full community integration, or participation in society, is the ultimate goal of rehabilitation. Community integration is defined by three main areas: employment or other productive activity, independent living, and social activity.

The HUB programme should provide opportunities in the following community integration domains: Housing, Employment, Education, Health, Leisure/Recreation, Spirituality, Citizenship, Social Roles, Peer Support, and Self-Determination. This can be achieved through developing local connections and linking with local statutory and voluntary service providers and support networks based in the participant’s local community. To achieve these local connections, staff and participants will need to lead a process of Community & Network Mapping which will discover and continuously update the resources available.

Ensuring Quality:

A primary consideration of the service will be the development of a quality personcentred systematic programme, which will be trauma-informed and will provide a safe and supportive environment, offering sensitivity to participant experiences, providing opportunities and encouragement, and ensuring participants can lead both the direction and pacing of their programme.

Participants will be offered an opportunity to develop a Recovery Action Plan using the Recovery Context Inventory (RCI). This in turn can be integrated into the person’s PCP.

Staff will develop and co-ordinate training and support programmes to facilitate health, wellbeing and recovery. Where participants have an interest in work, there will be a need to liaise with vocational training and employment agencies to facilitate this outcome.

Joint working between the centre and the participants’ supports including multidisciplinary/support teams, and where relevant, family and friends, is key to a successful HUB programme.

Staff can deliver support from the centre or out in the community. The HUB can offer online activities and Outreach / In reach support, where a staff member can work with the person over the phone or via Teams.

2.1 Programme Objectives

The HUB model has been designed to:

• focus on the person’s unique strengths and communicate a belief in the capacity to learn, grow and change

• support participants’ psychological, emotional, spiritual, physical and social needs

• ensure active citizenship and community participation, as defined by the participant, is central to their journey

• create an environment which supports the recovery of each person

• progress participants to more integrated settings

• bridge the gap between the programme and the community

• provide more choice and develop plans to meet those choices - participants who will determine their future and direct their own life plan

• provide activities that enable participants to meet goals and improve general life skills

• create trusting relationships which are key determinants in supporting social inclusion and active citizenship

• maximise independence

• support the creation/facilitation of employment links with jobs clubs and supported employment etc.

2.2 Programme Outline

The staff will help facilitate and assist participants to form and/or identify existing support systems and to fully participate in community living. It is important for all individuals to have support systems in place, whether it is friends, family, neighbours, clinical teams etc. The staff will focus on helping participants develop and/ or strengthen, as required, support systems for true community integration. In this way, the service will strive to cultivate the local community as an important resource and in addition, support participants to develop useful links with their own communities.

Programmes may be directed from the base location or other multiple HUB locations in the community/EVE network, as appropriate to the programme.

The programme will dovetail with the national standards of New Directions and Sharing the Vision.

The HUB programme provides a mix of structured and semi-structured psychosocial rehabilitative supports. The degree of structure and the mix of service elements vary according to the need identified by the service and its participants. A mix of services allows participants to engage with different programme activities at different times, as their needs change.

2.3 Programme Delivery

The programme will use a semi-structured approach with activities occurring during the day, based on need. A diagram outlining a sample day’s schedule/timetable is presented overleaf for illustrative purposes. For example, as we can see John is taking part in an external ‘Silver Surfer’ course in his local library from 10am until 11am. He returns to the HUB to take part in a Communications session at 11.15am until 12.30pm, he has some lunch and then, via the PATH module, he takes part in a social and recreational visit to the museum as part of this programme.

MONDAY

JOHN X TIMETABLE

Silver Surfer course in local library (10am - 11am) (CATCH)

Communication Skills (11.15 - 12.30pm) (Life Skills)

Museum visit (1.30pm - 4pm) (PATH)

MARY B TIMETABLE

Shopping for Breakfast cookery (9.30am - 10.30) (Life Skills)

Wellness Calls (10.30am - 11am) (Outreach)

Breakfast Cookery session (11.15 - 12.30pm) (Life Skills)

Local community mapping (1.30pm - 4pm) (CATCH)

There will be several activities available based on a timetable. Each participant will access activities as per their individual timetable. These activities can be derived from the individuals’ goals as set in their PCP. External activities (via the CATCH module) will be facilitated alongside individualised key worker meetings, and a selection of centre/alternative HUB-based activities are offered for those who are not engaged externally.

Each staff member will facilitate skill sessions/projects along with activity sessions, both centre-based and community-based. External instructors, e.g. ETB, VEC, sessional instructor etc., where feasible, can run programmes internally on various days alongside the other activities. Participants will be encouraged to access external, e.g. ETB, VEC or other communitybased provision, where possible, as part of the community integration segment of the programme.

PAT H TIMETABLE

WRAP group (10am - 12.30pm) (Life Skills)

Goal Setting (1.30pm - 2.30pm) (Life Skills)

Key working & PCP meeting (2.30pm - 3.30pm) (1-1 Support)

2.4 Key Elements & Empowering Opportunities of the HUB

The following are the empowering opportunities and key elements of the HUB that have been developed to support participants to be active and contributing members in the community.

1. Discovery

2. Life Skills (LS)

3. Transition Planning (TP)

4. Community Access & Training for Continued Health (CATCH)

5. Participant Alliance Through the HUB (PATH)

6. LINK

An overview of these elements will be given over the following pages.

Discovery Phase

Week 1

STEP 1: LEARN

Individual commences service and orientation.

Assign a key worker to the Individual.

Facilitate key worker meetings.

Week 2-5

STEP 2: DEVELOP

Week 6-10

STEP 3: DELIVER

Establish a working relationship with individual as their key worker.

Develop an initial Personal Profile and identify short and long-term goals through key worker meetings.

Begin discussions on developing a Personal Profile.

Observe and engage with the individual.

Week 11-14

STEP 4: REFINE

Collaborate with the individual to identify areas of interest, required supports, and available resources.

Support the individual to begin developing their Personal Profile.

Explore potential pathways for personal and skill development.

Support the individual to engage in relevant programmes.

Week 15-17

STEP 5: PROGRESS

Actively encourage the individual to engage in programmes aligned with personal goals.

Seek individual feedback on experiences and progress.

Support the individual where required to take part in structured programmes.

Initiate the development of a Person-Centred Plan (PCP).

Document learning and insights gained.

Review and finalise the initial draft of the Personal Profile.

Finalise the Person-Centred Plan (PCP) in collaboration with the individual.

Define the individual’s role and level of participation in ongoing programmes.

Confirm and agree on the necessary resources and supports for continued engagement and development.

2.4.1. Discovery Phase

The Discovery Phase in the context of the HUB occurs when the person starts on the programme. Whilst the timeframe for this will vary person to person, we estimate that this phase can extend for up to 17 weeks or more if required.

It offers the individual the opportunity to get to know the programme, get to know the staff, service users and also provides dedicated time for the individual and their key worker to get to know each other. It provides individuals with the skills, knowledge, and motivation to gain access to, understand, appraise and apply information to make effective decisions about progressing through the programme, about community inclusion and how to take appropriate action to achieve their individual goals. Spending 1-1 time with the person will give staff the opportunity to find out more about the person and the things that matter to them.

The process of the Discovery Phase involves gathering information using a person-centered approach to guide the development of a customised programme for the individual. The benefit of this aspect of the programme is that efforts focus on the individual’s abilities and the things they do well. It provides the key worker with a way of focusing on the individual’s strengths and interests in a way that is both positive and empowering.

The structure of the Discovery phase is broken down into five distinct areas (as depicted in the image on pg. 15.

1. Learn

2. Develop

3. Deliver

4. Refine

5. Progress

Learning

Learning starts on day one and looks at the areas of: commencing induction, being assigned a key worker, taking part in key worker discussions, looking at who might make up a person’s Relationship Circle and going through what a Personal Profile is, what it looks like and the information that goes into this document. This aspect of the Discovery Phase takes approximately four weeks but will be person-led and the duration may vary.

Develop

The Develop section looks at building up the key worker relationship and taking part in key worker meetings where the individual can set initial goals, make a draft of a Personal Profile, which will be further added to as we go through this process, and taking part in activities within the programme with other participants. Again, this will be personled, and the duration of this section could be two to four weeks.

Deliver

The Deliver section of the Discovery Phase looks at refining the Personal Profile, supporting individuals to choose goals which are meaningful to them, informed by keyworker discussions, developing

an initial programme and taking part in activities/sessions, e.g. self-advocacy, goal setting, managing stress, communication skills, decision-making, understanding emotions, problem-solving skills, personal empowerment, lifestyle balance, mindfulness, community inclusion etc. This section may take up to six weeks to complete and is person-led.

Refine

The Refine section looks at agreeing and finalising the individuals’ Personal Profiles and initial Person-Centred Plan, taking part in sessions (as above) and giving feedback on learning to date. This section may take up to four weeks to complete and is person-led.

Progress

The Progress section looks at agreeing the individual’s timetable and co-designing their programme, and agreeing the resources and supports needed. The entire process can take up to 17 weeks to complete but may be longer as this is a person-led process.

Some tips to support participants in creating Personal Profiles and engaging in planning next steps:

• You can learn a lot about the person in environments where you have not seen them before, e.g. community, groups outside the centre etc. so this can help to build a rounder picture of the individual.

• Do not limit key worker meetings to the usual places and times within the centre, go for a walk, café etc. and vary the times, e.g. morning, midday and afternoon meetings, if this is helpful to the engagement process.

• By observing and listening closely at this stage, the foundations can be laid for finding successful places, activities and roles that can be accessed at a later stage.

• Support and encourage personal choice and interest in different areas.

• Keep a record of interests, hobbies, positive responses to activities etc. that can be referred back to and used later when supporting people in creating/ updating Personal Profiles and/or planning next steps.

• Be flexible and open in approach whilst getting to know each other.

Life Skills

2.4.2 Life Skills (LS)

The Life Skills Programme is designed to support participants, at their individual pace, to develop the skills needed to live independently in the community.

Semi-structured / co-facilitated activities address the specific needs of participants through targeted group programmes. These are based on goals set by the individual at key worker meetings and person-centred planning meetings. They also provide the added value of participant involvement in the service through peer-support and peer learning. The structured programme elements aim to support the social and living skills of participants through a variety of group activities in a safe, peer-supported environment where participants feel accepted. Some of the core life skills offered may include:

• Personal Development – Core element (examples below)

• Self-Advocacy

• How to communicate effectively

• Managing Emotions

• Managing Stress

• Personal Empowerment

• Decision-Making

• Goal (Outcome) Setting

• Developing assertiveness skills

• Problem-Solving

• Home cooking, which may include:

• Shopping for groceries

• Preparing nutritious, well-balanced meals

• Accurately managing a budget

• Numeracy & Literacy

• Independent Living Skills

• Mindfulness

• Wellness Recovery Action Planning (WRAP®)

• Recovery Planning in Action

• Smoking Cessation

• Communicating and working with health and medical professionals

As well as developing specific skills, participants are encouraged to explore aspects of themselves through participation in a range of creative pursuits, e.g. music, drama and writing groups, and art and craft activities both within the centre and within the community.

Participants are encouraged to build on their strengths to support and/or increase their involvement in community activities. The programme will be flexible enough to accommodate transitional periods during which a participant may test moving out of the programme with the knowledge that it is still available to them should the need arise. Transition planning is woven throughout the programme with a view to enhancing opportunities for the individual, then they are ready to leave the service, i.e. before the two years, at two years or during a period of agreed extension to provide the necessary supports to transition.

Programme activities will also include those to support participants in their recovery, fostering new goals and ambitions, and coping with challenges using a range of supports and resources. These activities may be provided through WRAP® or by EVE Slánú, the Primary Care Team or jointly with community and/or support teams, individually or in groups, where possible.

How will this look in the day-to-day HUB service?

Timetabling:

Individuals, once they have completed the Discovery Phase, will have an individualised daily/weekly schedule or timetable of events (including core Personal Development modules), activities, sessions and 1-1 meetings. This process is person-led via their Person-Centred Plan and the SMART goals set out in this plan.

Planning:

Planning and scheduling will be key here as staff will need to factor in time to have 1-1 meetings with individuals, time to link in community connections etc. and also to deliver some of the core and identified group sessions being run throughout the week. For this reason, an individual staff daily/weekly schedule will also be required and will be key to this process.

Material Development:

Staff will need to factor in time to develop a session plan with supporting materials / resources, e.g. personal development, life skills etc. that they will facilitate. The plan and supporting resource materials will vary based on session duration and topic. Some sessions may be of a shorter duration, e.g. four weeks and may be more practical or conversational style, which will need less materials developed. Others may be longer in duration and may need more materials. These should be saved on the shared drive where they will be a shared resource accessible to colleagues in other locations and to the Quality Assurance department and Regional Manager for review.

Delivery:

These sessions can be peer-led, cofacilitated and/or facilitator led. The sessions are not academic in nature, they are centred on life experience. The sessions can be a combination of lived and professional experience. It is important to note that staff are not expected to be the ‘expert’, knowledge can, and should, come from everyone.

Short Courses:

Our Life Skills sessions can be open to everyone, individuals from the community and HUB alike. They can be held onsite and/or off-site, where needed. We welcome each individual’s valuable perspective and provide the opportunity to join a community of people with shared values.

Partnership Working:

Partnerships can be extremely valuable here, e.g. Healthy Food Made Easy, ETB tutors, sessional tutors etc., in opening the HUB to community but also allowing HUB service users the opportunity to engage in activities we organise in community venues with individuals from the community, e.g. connect café events, yoga in the park, community art workshops in the library etc.

While the sessions offered can be diverse, they all have the common goal of providing individuals with the knowledge and tools to find the most meaning, confidence and enjoyment in day-to-day life.

Transition Planning

2.4.3 Transition Planning

Both moving on from the HUB programme and engaging in community activities whilst attending the HUB should be seen as a process and not something that can be addressed in a single event.

Transition planning is woven throughout the HUB model via the goals individuals set at key worker meetings, at Person-Centred Plans and moving from the Discovery phase into other elements of the HUB.

Transition planning is key to ensure the individual doesn’t get ‘stuck’ in the programme/service. It enables the key worker and the individual to identify key supports in an effective time frame before progressing onto other services, employment or education at the end of the HUB programme. The key worker needs to work with the individual to decide if additional supports are needed based on the person’s goals.

To ensure transition planning is interwoven throughout the programme, the following supports are necessary:

1. Early preparation - Be clear at the start what the duration of the programme is and when the person will be due to exit.

2. Key worker is in place.

3. A formal planning process is in placePerson-centred planning and key worker meetings occur which have SMART goals identified.

4. Good communication is essential.

5. Empower, encourage and enable the individual to self-manage - Where necessary, support people to take increasing responsibility for decisionmaking gradually and ensure the individual’s relationship circle/circle of support are included, where they wish.

6. Be person-led at all times.

7. Evaluation and feedback is key.

Once a person starts in a HUB service the transition process will commence. The aim of a transition is to minimise the impact of change that is occurring for the person and to create an individualised schedule that meets the person’s goals, needs and requirements in a person-centred way. This is as per The United Nations Convention on the Rights of Persons with Disabilities, New Directions and Sharing the Vision.

Community Access & Training for Continued Health (CATCH)

2.4.4 Community Access & Training for Continued Health (CATCH)

The CATCH programme is a blended model (i.e. some activities take place on site and some in off-site community settings) approach, tailored to assist participants by helping them connect with exciting recreational and educational opportunities in the community.

The programme is more than community participation, it focuses on developing skills that promote meaningful community integration and on abilities that allow individuals to become more self-reliant. Some of the areas of focus include:

• learning and practicing self-advocacy skills,

• pursuing educational opportunities,

• participating in social recreational activities,

• becoming aware of the community,

• participating in volunteer work,

• exploring work opportunities, and

• learning about personal safety etc.

Involvement in leisure activities, recreation, and life skills development offers additional possibilities for success in everyday life. The CATCH programme supports individuals in achieving a greater quality of life, sense of wellbeing, and meaningful community inclusion. Participants are encouraged to develop positive connections and resources so that they can be part of a community in which they feel included and valued.

In order to support people in their wellness journey real progress on community inclusion means a commitment to ensuring all the

people we support have many opportunities to fully participate in the community, and to actively create communities that seek out and welcome the participation of everyone.

Full meaningful community inclusion is when individuals have the same opportunities as everyone else to create a home, develop relationships with families and friends, find a job or complete education, discover communities of people with similar interests, or explore recreational or cultural opportunities.

Each person should have the:

• opportunity to work toward community inclusion, even if someone else believes that they are not yet ‘ready’ for community participation.

• power to make their own decisions about what community inclusion means to them, to choose the supports that will help them achieve their goals, and to identify the best ways to manage any risks that may be involved (selfdetermined goals etc.).

• chance to pursue participation in areas that are important to them rather than being restricted to what is available or believed to be important by society.

“People don’t need more referrals to mental health services, they need referrals to life and community.”

(Rapp,1996)

To support community inclusion, the individual needs to be an active participant. Active involvement begins with individuals identifying for them what is missing, what needs to be retained and/or what they would like to further develop in terms of community inclusion. Staff need to work with participants to get to know an individual’s needs and wants, as well as increasing knowledge of the resources available in the community. There is no right path and no right approach.

With multiple paths and avenues available, it can be hard to know where to start. What may work for one individual does not work for another. There may be religious, cultural, personal and family beliefs which influence decisions. Some influences may emphasise independence while others promote interdependence. As a result, we have developed a Community Mapping and Networking guide that details a step-by-step process that can be followed.

Where to start:

The Individual and Their Hopes and Dreams

A person’s Personal Profile and PersonCentred Plan may provide a direction for CATCH activities of most interest. It is suggested that key workers spend time with each person reviewing these resources and discussing potential community activities of interest. Participants may enjoy varied activities such as book clubs, knitting classes, swimming, dancing, or attending local community events. Many local communities have Men’s Sheds, DIY groups and women’s groups, and Community Centres, which offer a wide variety of activities for individuals.

Some tips include:

• Get Connected One Day at a Time – build up a regular routine, if going to a group try to go each time the group is on

• Plan for hiccups – have a back-up plan, e.g. if the bus doesn’t turn up, what does the individual do? etc.

Community Connections:

Connecting with community resources is often a trial-and-error adventure. Some activities may happen more naturally for people while others may require more work and perseverance. It can be helpful to support participants in reflecting on what is working now for them, as well as their future goals. Many forms of technology, such as smart phones, laptops, apps and social media, have expanded the ability to connect and consequently some individuals may find it helpful to research information online, i.e. clubs, events etc. Participants may be interested in connecting with groups on social media or gathering information from local websites or more traditional sources such as libraries, newspapers, shop bulletin boards, GPs waiting rooms, and community centres.

Other service users may provide an additional resource through sharing information about community opportunities and their experiences. It might be helpful for staff to facilitate discussions where information can be shared. For example, were do others like to go in their community? Where do they work and/or volunteer?

To help with the journey, key workers/ staff should reach out to other services, organisations, community groups, colleges etc. and start by making a list of local and regional resources. From here key workers can build a Community Assets database/ spreadsheet. To do this key workers/staff will need to carry out an audit or profile of the local community and/or the individual’s local community if they live outside the area of the HUB service.

A Community audit or profile can be made up of the following:

• Government agencies

• Community groups

• Services

• Education and training providers

• Employers

• Leisure facilities

• Key people, etc.

This profiling can be done on site via Facebook and internet searches etc. or offsite in the community via ‘feet on the street’ style activities. The off-site piece creates opportunities for networking and building up rapport with individuals/groups and to connect with and/or creating opportunities with groups who do not have a digital presence.

Some Tips:

• Planning is crucial – during weekly CATCH sessions, you can plan out where to go, what to research, putting together an itinerary etc.

• Clear goal-setting – you need to be absolutely clear on what you are searching for – it focusses your efforts, and it will ensure results.

• Goals (outcomes) must be SMART goals.

• Set boundaries – geographical and limits (time, need to know, don’t need, nice to know).

• Facebook groups are a great steppingstone, which can lead to more connections and networks.

• Level of support – different people require different levels of support. Work with the individual to determine just what level of support is right for them to make successful changes without undue pressure.

• Listen to what the person wants, encourage them to collect the information (or get it with them), support them to make appointments, accompany them to meetings/interviews etc. and if needed, negotiating on their behalf.

Making Connections & Relationship

Building:

Planning and consideration is key when it comes to introducing or linking the person to new groups or organisations. You will need to establish if the individual would like you to go to the first initial meetings/activity etc. Let the individual lead you, respect their wishes and support where necessary. Ensure the individual is as prepared as they can be, e.g. what bus to get, that they know what questions to ask if looking for a work placement or course etc.

When at the meeting or visit, be clear on your role – are you supporting the person, there for reassurance only or there to gather the information? Always encourage.

Finally, supporting the person in relation to change is key. The individual’s Relationship Circle / Circle of Support will be key here. The individual may be fearful or have misgivings about moving from the security of the HUB to the community. To make sure the transition is a smooth one, the individual may need the support of familiar people, e.g. a neighbour may go to the Men’s Shed and could give the individual a lift.

Some Tips:

• Ensure conversations are personled rather than time-restricted, allowing for meaningful and engaging interactions without focusing on the clock or limiting the number of exchanges.

• Be fully present, responsive and reliable.

• Offer support, where needed.

• Demonstrate a commitment to assisting individuals to live ‘a good life’ at a pace and in ways that they themselves endorsed.

• Help set up an individual’s relationship circle or circle of support and facilitate regular meetings.

So what does this look like in the day-today operation?

To roll this out in the day-to-day activities of the HUB, CATCH can take many different forms and may happen off site as well as onsite.

• You can work 1-1 with an individual –this starts from day one by building up a relationship and trust via the key worker

process. Completing the Personal Profile and setting goals. Working with the individual on their community profile, planning meetings etc.

• You can run frequent CATCH group sessions on-site using a room with PCs and internet access to review Facebook groups, social media platforms etc. for new connections, up-coming events, checking on existing connections and linking in with established networks.

• You need to schedule time to profile/map individual’s local communities and/or the HUB’s community to establish upcoming events, make new connections. This can be both onsite via research and off site via ‘feet on the street’ activity and/ or networking, meeting new connections, establishing links etc.

• You can offer ‘community update’ bulletins via newsletters, video slots, media news segments that can be shown on the screen on-site and up on your social media platforms, during LINK sessions.

• The community board needs to be updated regularly.

• You need to continue to link in with existing and established networks and connections to offer them access to sessions run on site, e.g. Recovery Planning in Action, WRAP® etc. and to identify any new avenues to support new individuals.

• You need to keep the Community Profile/ Assets Database up to date.

• You need to ensure any promotional literature you use is kept up to date and in stock. This includes presentations, social media accounts, leaflets, posters, banners etc.

Participant Alliance through the HUB (PATH)

2.4.5 Participant Alliance through the HUB (PATH)

PATH is a forum for various clubs and activities that occur within the HUB which are ideally peer-led, but which can be co-facilitated or staff facilitated and/or external tutor/guest speaker led.

What ultimately makes a successful alliance is that it is flexible to meet the needs of the participants, it is social in nature and it nurtures and supports the individual. We know from research that the following are key to the success of any alliance or club:

• The relaxed, informal nature of the clubs

• The participants’ active involvement in the running of their own club/alliance

• Outings and social occasions

Each club differs and the format for the group varies. What goes on in the alliance is led by the participants. Checking in with the participants is essential. Some of the following elements may happen:

• Small group discussion/general conversation

• Large group discussion/general conversation

• Activities (e.g. exercise, music)

• Cup of tea/coffee

• Outings to local places of interest

Group-based, participant-led peer activities aim to assist individuals to increase connection with community and others, increase social supports, decrease social isolation and support skill development and achievement of individual goals through group processes.

Peer-to-peer learning occurs when participants engage in collaborative learning, where they learn from one another, not a facilitator or staff member.

Some benefits of PATH include engagement in fun activities, enjoying the social interaction that comes from the activity, involvement in organising and leading group activities (particularly where there are peer led activities).

Examples of such alliances that are facilitated via the HUB are special interest/ hobby groups, support groups, e.g. mental health engagement, social activities groups, collaborative project groups, rep committees, sport groups, senior living groups, discussion groups, walk and talk group, youth group etc.

Some case examples can include the

Castleview Senior Living group

The Castleview Senior Living group which provides community-based recreational and social services geared towards those 55 years and upward. A diverse range of life quality enhancing activities are provided and sourced, including enriching senior education classes, engaging recreation and leisure activities, health-promoting fitness classes, and empowering community involvement opportunities.

A Senior Living programme is more geared towards meeting the unique needs of seniors. An example of this is the ‘Getting Started’ training programme offered by Age Action throughout the Dublin region. ‘Getting Started’ is a training programme for older people to encourage and help them to use computers, the Internet and mobile phones. Classes are run by volunteer tutors with small groups of learners, in local, non-formal learning settings.

Youth / Beginnings group

The Youth / Beginnings group focuses on giving young people (18-30) space and time to explore what recovery means to them and to talk about their concerns and opinions on life challenges and mental health. It also provides a space to reflect on one’s strengths, resources and new opportunities which can be used to support recovery. This may take two forms; one element will be the group meetings/session times and the second element will be facilitated sessions run by staff and or peersupport worker or someone with lived experience. These sessions can be centre-based or communitybased, depending on the available programmes. This programme can be supplemented with information from the ‘Minding Your Wellbeing’ programme, which can be accessed via the following LINK on the HSE website:

https://www.hse.ie/eng/about/who/ healthwellbeing/about-us/mindingyour-wellbeing.html

Please note that the above group activities are examples only, they do not need to be delivered and are open to all in the HUB and not age exclusive.

Special Interest / Hobby groups

Special Interest / Hobby groups create an atmosphere where people can comfortably come together to learn and develop new skills while enjoying conversation and connection. These can also become a stepping stone where these activities can move into the community.

Social hobbies facilitate more casual, free-flowing conversations while individuals focus on a task at hand, e.g. gardening/allotments, art, knitting, book club etc.

These can take place onsite and offsite in a community setting, e.g. library, allotment etc. during core hour and or/ non-core hours. Over time individuals can progress to their local community book club, knitting group etc.

Advantages of special interest / hobby groups can be as follows:

• Reducing feelings of loneliness and isolation

• Increasing a sense of belonging

• Providing emotional support

• Learning and growing through shared knowledge, skills, and experiences

Participant Representative Group

A Participant Representative Group can be set up in your location, if not already in place. This is a group of elected participants who act as a voice for all the participants in their location. Individuals can do this by giving feedback on concerns, needs, suggestions or queries which are made known to them. This may include issues that are of concern to all participants in all EVE centres, not just their own HUB service. The Speak Up guide is a useful resource to use when setting up a Representative Group in your location.

Connect Café

The Connect Café aims to be a peer-led initiative. Participants will be encouraged and supported to organise and run a Connect Café. This Connect Café can take two forms. The first can be an event or a topic focused event, e.g. Laughter Yoga, a presentation from a local dietician, Discussion on Wellbeing, Local Area Partnership talk etc. which can be followed up by a Q&A session and/or a chat over a coffee. The second form is more of a social catch up which is informal and does not have an event tied into it.

The implementation of a Connect Café slot weekly is a great opportunity for community engagement and to implement the recommendations in ‘Sharing the Vision’. The objectives of this activity include providing an innovative solution to reduce isolation for those experiencing mental health difficulties, reducing stigma, increasing supports, promoting wellness not illness etc. When hosting the Connect Café

in the community this could increase opportunities for participants to feel part of their communities and to create an open safe public space through engagement with local café business owners.

The Connect Café activity is peer-led and can be enhanced and/or supported by guest speakers, sessional tutors or peersupport workers or individuals with living and/or lived experience.

The staff will support participant directed activities, e.g. extending invitations to representatives from a wide range of community organisations and services to meet with and address participant issues via guest speakers, wellness activities etc. Participants will also be involved, wherever possible, in prioritising activities, investigating resource implications, running activities and evaluating activities.

CONNECT CAFE

PEER-LED

• Gives individuals the support and skills to build independence and work together as a team.

• Follows the CHIME framework: Connectedness, Hope and optimism, Identity, Meaning and purpose, and Empowerment.

• Offers additional opportunities to support and manage wellbeing and mental health through events.

EVENT / TOPIC

• Offered frequently as per schedule

• A space for fun and positive interaction, peer support, special guests

• Each Connect Cafe event could feature a speaker who delivers a short talk on a topic of interest or an activity. Following the talk or activity individuals can ask questions and/or catch up over a coffee.

Please note that the examples given are of possible groups but are not prescriptive (excluding Connect Café). Areas of participant interest will inform the content and purpose of the PATH groups. The groups can initially be supported by a staff member and/or peer-support worker, but these supports can be tapered off once the groups gets up and going.

Payment for activities will be funded by participants and positive risk-taking must be encouraged, e.g. going to the coffee shop, cinema or supermarket without support.

SOCIAL CATCH UP

It’s a place where participants can come together where they will:

• enjoy good company

• savour delicious coffee (or tea, if that’s your preference)

• engage in inspiring conversations

• get connected and be empowered in their wellbeing

Positive risk-taking empowers people to discover new experiences, sources of joy and fulfilment, and a sense of meaning. The strategy includes taking carefully reviewed risks to provide positive outcomes for the people we support and focusing on what people can and already do. This ensures we are applying a human rights-based approach to our programmes and services.

LINK

For individuals who have completed the HUB programme but want to stay connected through social events and short courses.

1.

SHORT COURSE

Individual attends for dedicated course/sessions on dedicated days/times to work on any unmet PCP goals.

2. LINK SESSION

Individual invited to attend for one half-day per week for dedicated sessions to get updates on community events, groups, clubs, community links etc. via CATCH.

2.4.6 LINK

The LINK programme, which is for those participants who have completed their HUB programme, emphasises social and recreational activities to promote peer networks and reduce community isolation.

It aims to provide an opportunity for past participants to maintain a connection with the HUB by offering opportunities to attend for specific events/occasions (maximum two half-days per week, e.g. Monday morning and Thursday afternoon) without requiring formal commitment. It is anticipated that the LINK could offer an ongoing source of connection and support in past participants’ lives and its informal nature lends itself to innovation, creativity, peer-support and experimentation.

The LINK programme can take two forms:

1. Dedicated short courses

2. LINK module

These elements are discussed below and overleaf.

Dedicated Short Courses:

Each location may offer dedicated short courses for example a six week programme on Healthy Eating. In addition to past participants from HUB, individuals who access other services, community groups, partnership links etc., can express an interest and submit their names for attendance on specific courses run within the HUB when places/slots become available. These individuals will need to complete an application form and have support available to them from an external person, for example, a community nurse etc.

LINK - SHORT COURSE

Key worker discusses and agrees options with the participant

The individual completes and submits the LINK course form

Invited back for session, i.e. nominated day and time as per timetable

Session is completed 5

Link Session

Link activities are centre and/or community based, e.g. coffee and chat, community update meeting, social group etc. Where possible and of interest, individuals should be supported to engage with existing community groups, e.g. book clubs, cinema clubs, library activities, forum groups etc.

The LINK module may be used by past participants as a way of continuing contact with the service, even though they are accessing other services or participating in the community in other ways, such as through employment. It can also act as a pathway to participate in more structured programmes within the community, and where appropriate, participants will be assisted in making this move.

LINK SESSION

ATTEND

Invited to attend once per week (half day)

Staff should support participants to explore engagement in other community activities in order that the LINK doesn’t become the sole activity.

Participants, prior to exiting the HUB programme will be invited to complete a contact form and, where provided, the information on this form will be used to contact participants when any LINK activities are being offered.

To access these supports, former HUB participants will be contacted via the Outreach/CATCH element of the HUB when any activities are being arranged and/or short courses/information sessions are available.

For individuals who never attended a programme in the HUB or attended a number of years ago, these activities can still be accessed through a nominated member of the clinical team and community networks/ links with the HUB, who can offer additional supports. These individuals will need to complete an application form and submit it to the centre. Programme flyers will be available on a periodic basis and will be circulated to all networks/links for dissemination to all service users. If an individual would like to attend a particular short course, they can contact the centre to book a place. If there is no available place, the individual’s name will be kept on a shortlist for cancellations and/or the next time the course is being run.

Once an individual contacts the centre their contact details are kept on file in the outreach programme and they will be sent notices on upcoming events etc.

A local strategy should be developed and agreed in relation to the following:

1. Participants who sign up for an activity and later don’t attend e.g. taking steps to support participants in addressing barriers to attendance.

2. Participants who have not accessed the programme in a number of weeks, return to the programme and staff have concerns about their health, safety or wellbeing, e.g. nominated link staff to discuss concerns with the person and contact a supporter.

Introduction to the HUB Programme (Continued)

DISCOVERY PHASE

An individual will start the Programme & work through a Discovery phase where the individual and staff get to know one another. An initial Personal Profile will be developed.

TRANSITION PLANNING

The individual will be supported to think about their plans for the future throughout their programme. This process starts when they walk in the door. It is informed via key worker meetings & Person-Centred Plans. The last six months is dedicated to working on an agreed progression/exit plan.

LIFE SKILLS / ACTIVATION

A tailored programme will be designed for the individual to develop key life skills (for example, cooking, budgeting, work skills). These will be based on their PersonCentred Plan. This is updated via feedback, key worker meetings and updated PCPs/ goals. Can be offered on site, off site or a blend of both.

COMMUNITY MAPPING CATCH

Working with other participants, the individual will identify what is in the community, what supports can be offered to whom, by whom and when.

PATH

Co-produced & peerled group work to meet identified need, e.g. young adult groups, cinema clubs, men’s sheds etc.

LINK

Individuals can link back into the centre in a number of ways. e.g. Dedicated short courses or for LINK sessions.

2.5 Additional Features of the HUB

Outreach Support (OS)

Outreach support involves key workers and/or participants contacting participants (via phone, sending cards etc.), with their prior permission, at their homes/hostels/ hospital to provide support, encouragement and to check in with those whose level of contact with the centre has diminished or who have been out of the centre more than usual. Levels of outreach support will be agreed at the beginning of the programme between the participant and the key worker, whereby the participant agrees to the appropriate method of contact, e.g. mobile phone, home landline, the appropriate contact person, (e.g. themselves, appointed family member, CMHN etc.) and the agreed period of absence, (e.g. after two days of no attendance or contact).

This is important in supporting participants who may be experiencing difficulties in accessing the centre or a participant who is too unwell to attend the programme and assists them maintain links with the service.

In Reach

Similar to the Outreach system, participants who cannot physically be present can phone the HUB and/or their key worker to assist with support needs. This can also assist with community support needs, to discuss any concerns, to have a key worker meeting if they cannot physically attend etc.

This is important in supporting participants who may be experiencing difficulties in accessing the centre or a participant who is unable to attend the programme and assists them maintain links with the service.

Hybrid Participation

Hybrid programme participation combines both in-person and online sessions / support. Hybrid means some participants are physically present in the HUB and attend in-person and other participants attend from their home or elsewhere (may be due to health, travel issues, preference etc). All participants attend the same session (at the same time) and can interact with each other and the staff member quite freely via camera and, at times, headphones.

It offers enormous benefits for staff and participants, and it can also help and improve outcomes for some individuals.

Benefits of hybrid participation can include flexibility and accessibility, personailsed learning, enhanced engagement and improved communications and collaboration. By embracing this innovative approach, staff can create more flexible, personalised, and provide engaging learning environments that cater to the needs of all participants.

2.6 Programme Timeframe

The programme is person-led so each individual’s timeframe may vary depending on their individual support needs, attendance, and goal attainment, for example.

Funding for some services may stipulate a two-year duration with additional time, if needed, to meet individual need.

The individual will participate on an agreed frequency of days per week. The first three months, or longer, depending on the individual, will be the Discovery phase. During this time, the individual will develop a

personal plan, goals etc. and their remaining time will be made up of time in the HUB / community.

Internal evaluations will take place every 17 weeks to assess the impact of the programme and make changes as required. The focus will be on progression to more mainstream or community settings. Where a participant has used support tools such as the Recovery Context Inventory, keyworkers can work with participants using goals identified to support participation in their community.

If for any reason attendance is not maintained over a period of time the participant will be invited to a meeting with centre manager / keyworker to explore reasons for disengagement and may be exited from the programme, should they no longer want to attend. Should the individual wish to reattend the HUB programme, they will need to reapply. Waiting lists may be in place dependent on numbers within the centre.

Section 3 Programme Methodology

3. Programme Methodology

The HUB programme is person-led with the individual’s Person-Centred Plan being the driver of their individual programme of support.

Support should focus on achieving the person’s aspirations and be tailored to their needs and unique circumstances.

A person-led approach:

• supports the person, at the ‘centre of the service’, to be involved in making decisions about their life

• takes into account each person’s life experience, age, gender, culture, heritage, language, beliefs and identity

• requires flexible services and support to suit the person’s wishes and priorities

• is strengths based, where people are acknowledged as the experts in their life with a focus on what they can do first, and any help they need second

• includes the person’s support networks as partners.

A person-led approach should support and enable a person to build and keep control over their life.

Our priority is to empower people to access activities to match needs, access support where required and access the community for other support needs whilst being supported by the centre where appropriate.

To ensure that each participant’s individual needs are met, a Person-Centred Plan (one every six months) will be developed allowing the participant to select a combination of support methods and approaches to be taken, in consultation with staff, that best suit their own requirements. The total programme duration will reflect the selection of support inputs, activity options and individual needs.

An individual timetable is developed for the person based on the support needs identified in the Person-Centred Plan and may include 1-1 support during the week, group sessions on areas of interest / need, accessing the community for external courses, employment opportunities / support etc.

3.1 The Programme Approach Summary

The overall approach to the programme will be purposeful and collaborative.

Principles underpinning delivery:

Keyworkers should encourage and support participants in taking action based on selfdetermined choice.

All approaches will be determined in a collaborative fashion and participant input will be at the forefront at all times.

Person-centred planning and key working will be key processes to this model. Government Policy, as outlined in ‘Sharing the Vision’, is that our mental health services should be recovery-oriented and reflect the user’s unique situation. The development and revision of person-centred planning is a key step taken to ensure this. Personcentred planning is another essential and indispensable component of a modern mental health service which supports recovery.

Operational:

A breakfast / morning meeting, where applicable, will outline the day’s activities, events and/or modules and any unforeseen changes to the current timetable will be clearly marked on a number of boards (i.e. Timetable, Calendar of Events etc.) throughout the centre.

Within the HUB model, a PCP will be carried out every six months. Short modules can be delivered in each timetable, for example, there may be two five-week sessions (Healthy Food Made Easy and Recovery Planning in Action), followed by a six-week session

(Managing Emotions). Staff members, alongside their manager, will develop their individual schedules/timetables which will encompass their 1-1 meetings, session delivery, community networking, 1-1 support, linking in with supporters etc. to progress goals. PCP completion can be weaved throughout the 26 weeks (e.g. between weeks 19-22 – must be completed by week 22 to give time for timetable and work plan development).

3.2 Assisted Decision Making

The Assisted Decision-Making (Capacity) Act (2015) (as amended) is about supporting decision-making and maximising a person’s capacity to make decisions. This Act applies to everyone and is relevant to all health and social care services.

This new Act assists in complying with human-rights obligations contained in the Constitution of Ireland, the European Convention on Human Rights, and the United Nations Convention on the Rights of Persons with Disabilities.

The guiding principles of the Act require healthcare workers to do the following:

• Presume every person has the capacity to make decisions about their life

• Support people as much as possible to make their own decisions

• Don’t assume a person lacks capacity just because they are making, have made or are likely to make what a healthcare worker, or another person, might perceive to be an ‘unwise’ decision

• Only take action where it is really necessary

• Be guided by the principle that any action should have the least restriction on a person’s rights and freedoms

• Give effect to the person’s will and preferences

• Consider the views of other people

• Consider how urgent the action is

• Use information appropriately

Each key worker must have a discussion with each individual in their key worker group to establish if the individual has a Decision Supporter. This must then be recorded on the Activity Tracker (Profile worksheet).

If an individual has a decision supporter, staff may be required to engage with a person’s legally appointed decision supporter under the 2015 Act. Staff may also be required to check the Decision Support Service’s decision arrangement register to see if a person has a decision supporter and/or to check that the decision supporter is working within the scope of the agreement.

How to learn more about Assisted Decision Making

The Assisted Decision-Making (Capacity)

Act 2015: Guidance for Healthcare Workers e-learning programme was launched on HSeLanD on 7th March 2023. This e-learning programme includes 3 modules:

• Module 1: Guiding Principles

• Module 2: Working with Decision Supporters appointed under the 2015 Act

• Module 3: Advance Healthcare Directives

This training programme should be completed by all staff.

In addition to the online training programme, HSE have a range of other resources designed to support staff in complying with the Act. These include:

A website, www.assisteddecisionmaking. ie, is accessible where most of the HSE’s resources can be accessed.

A pre-recorded presentation on the essential elements of the Assisted Decision-Making (Capacity) Act 2015 and what this means for staff is available.

A series of webinars help staff prepare for commencement of the Assisted DecisionMaking (Capacity) Act 2015.

A regular newsletter to keep staff informed of developments in relation to the Act. If you would like to join the mailing list for this newsletter, please email your request to adm@hse.ie. This is the best way to keep up to date with new resources as they are released.

A book “Assisted Decision-Making (Capacity) Act 2015: Personal and Professional Reflections” written by subject matter experts, experts by experience, health and social care professionals and others offering their perspectives on what we can expect from the Assisted Decision-Making (Capacity) Act 2015.

What is meant by ‘will and preference’? It is essential to encourage and facilitate the person to participate as fully as possible in decision-making. Even if a person, despite support, lacks capacity to provide or refuse consent, their past and present will and preferences remain important, and staff should, in general, act to give effect to

those will and preferences when it comes to deciding whether to proceed or not with a proposed intervention. The views of anyone the person asks to be consulted and of people who have a close, ongoing personal relationship with the person such as family or friends should be considered and may be invaluable in eliciting the persons past and present will and preference.

Will

Will incorporates a person’s values, personal beliefs, ultimate goals. ‘Will’ carries a stronger sense of determination or planning than ‘preference’

Preference

Preference means ‘a greater liking for one alternative over another’.

3.3 Staff Role

The focus of the HUB programme is providing the service user with support, activities and community opportunities that help them to live as independently as they can and be a part of their own community to the best of their ability. There is no ‘one size’ that fits all. Every staff member will come to this service model with their own unique set of skills and abilities.

The main role of the staff member is to:

• act as a key worker;

• support individual choice;

• provide a safe environment;

• be responsible for the day-to-day running of the programme;

• support the development of a person’s Personal Profile (one page), PCPs/RCI Recovery Action Plans, and any other

• planning tool to support person centred planning;

• support the implementation of PCPs/RCI Recovery Action Plans, where relevant;

• complete person-centred thinking tool documents with the individual to inform PCP development, such as assisting the individual to map their Relationship Circle/Circle of Support;

• work with the individual to achieve their nominated goals;

• assist the individual to integrate into the community; and

• deliver/facilitate programmes/learning sessions and monitor, evaluate & review same.

3.3.1 Staff Role - General (Attitudes/Values, Behaviour & Knowledge)

To be effective in their role, staff should endeavour to bring the following qualities to their work in EVE:

• Motivated.

• Adaptable.

• Good character.

• Participant focused.

• Communication skills.

• Quality / accreditation focus.

• Have a flexible approach.

• Insight into the impact of mental health difficulties/intellectual disabilities/autism on a person’s self-concept and everyday functioning.

• Understanding of mental health, intellectual disability, autism, alcohol, drugs and other issues.

• Understanding of the impact that

trauma may have in influencing peoples’ outlook and behaviours and working to create an environment which is safe and compassionate.

• Ability to negotiate & advocate effectively on behalf of service user.

• Empathy with people with mental health issues, autistic people and those with intellectual disability and other complex needs.

• Have an understanding and appreciation that all people (staff and participants) are neurodiverse and hence have different ways of interacting with and interpreting the world around them.

• Empathy with families/supports/carers of people with mental health difficulties, autistic people and those with intellectual disability.

• Implements organisational Policies and Procedures.

• Committed to own personal & career development.

• Solution-focused.

• Ability to act calmly in crisis/emergency situations & to deal effectively with challenging behaviour.

• Ability to act on own initiative & to plan, organise and prioritise work.

• Have the ability to work in a generalist / flexible role.

• Ability to lead, motivate and encourage.

• Willingness to engage in routine but necessary tasks, as well as challenging tasks of a more varied nature.

• Ability to break down task objectives to manageable components and maximise the potential for service user participation.

• Ability to learn, apply & impart knowledge of service programme specification/ model.

• Range of work-related skills and experiences of life.

• A belief in the intrinsic value of each person as an individual human being.

• Non-judgmental and sensitive to various service users’/members’ lifestyles, diagnosis, sexual orientations, living situations, family structures and age groups.

• Procuring external resources and supports required for the achievement of Person-centred / Recovery Action Planning goals with a specific focus on community participation and inclusion.

• Managing his/her working relationships in a manner which promotes co-operation and participation, and which is respectful of the organisation’s line management structure at all times.

Supporting effective community integration for participants requires staff to engage with each individual honouring their right to self-determination and to exercise choice in their decisions. It means that independence rather than dependence is promoted, but also that they facilitate access to peer, friendship, family, and professional supports if the participant wishes. It means that support is provided, as much as possible, to facilitate community integration and reduce the reliance on centre-based activities/programmes. It means that the use of mainstream resources is promoted whenever possible and the barriers that limit opportunities for participants from using these resources are addressed.

In addition, qualified sessional staff will be employed to deliver modules, where needed. The Sessional Tutor should have a minimum of one year’s relevant experience and or qualifications in the relevant area in which they tutor. Experience of working with people with mental health challenges, intellectual disabilities and/or autistic people is desirable.

3.4 Participant Profile

EVE HUB services are designed for people who:

• are 18 years plus, providing the service meets the needs of the individual.

• have experience of mental health difficulties, which are a priority concern for the person and for whom the programme is considered a ‘good fit’ by both the person and EVE, in order to progress their self-determined life goals (mental health focus) / Individuals with Intellectual Disabilities (ID service specific) / Autistic adults (Autism focus).

• are willing to engage with the programme

• are motivated to manage and cope with their lives more effectively with support.

The HUB does not have any educational entry requirements.

3.5 Task Analysis

To achieve this person-led, goal-driven programme approach, the following will need to be achieved:

Programme

• Develop & implement an individual timetable of activities based on the Person-Centred Plan for each individual

• Carry out community & network mapping

• Identify and attain necessary/appropriate programme funding/resources

• Identify and develop resources required for programme delivery

• Implement programme

• Create external community links

• Carry out key worker meetings

PCP

• Assist the individual with the development of their relationship circle

• Have a Personal Profile in place for each individual

• Carry out PCP’s / Recovery Action Plans

• Maintain links with the participant’s support team (family and friends where relevant and with prior consent) and external key workers as necessary

Evaluation

• Maintain records & Activity Tracker

• Carry out quarterly participant evaluations

• Provide updates and/or concerns to be addressed at manager and regional manager 1-1 monthly meetings

• Develop an annual service plan and annual report

• Carry out annual H&S checklists & selfaudit assessments

• Participate in system reviews, EASI Tool, quality system audits and external monitoring

The programme will be reviewed annually or as required based on participant or programme need.

Internal evaluations will take place every 17 weeks to assess the impact of the programme and make changes as required. EASI Tool focus group sessions can be built in here.

The programme will be monitored regularly with health & safety self-audit checklists, quality systems audits, system reviews, records and participant evaluations.

Communication is key and staff meetings should be held frequently.

Participant review meetings should occur weekly to allow a free flow of information to all staff in relation to support needs, individual concerns etc.

3.6 Programme Supports

The following programme deliverables will be available to programme participants:

• Induction/centre handbook

• Centre leaflet & promotional materials

• Programme resources

• Personal Profile

• PCPs

• Recovery Action Plans/WRAP Plans

• Programme/Community Directory

• Timetables/Schedules

• Records

• Activity Tracker stats

• Key worker meeting notes/records

• Personal file/records

• Annual service plans

• Annual reports

• Monitoring reports

• Audit/Review reports

Programme Management

4. Programme Management

Outlined below are a number of areas that are key to implementing an effective programme.

4.1 Person-Centred Planning

A person-led approach values autonomy, informed decision-making, and personal efficacy. Using person-centred thinking tools (available in the Staff Resources folder), staff will support individuals in identifying their needs, goals, and preferences. The process involves active listening, collaboration, coaching, and feedback to ensure ongoing support as goals evolve. The ultimate aim is to empower individuals to live a self-defined, fulfilling life, their way.

4.1.1 Personal Profile

During the Discovery Phase the individual will develop their Personal Profile (using the One Page Profile tool) with their key worker. A Personal Profile (or description) is a summary of person-centred information that others can use to get to know a person quickly and learn how to provide good support in the way that the person wants. It looks at a number of areas, as follows:

• What people appreciate about meThis section is a list of the individual’s positive qualities.

• What is important to me

This section describes what really matters to the individual. The people, places, routines, and aspects of their life that reflect who they are, and what is important to them.

• How best to support me

This section is what others need to know or do to support the individual to be at their best.

The individuals’ Personal Profile can be continually updated as needed by the individual and their key worker at key worker meetings, PCP meetings and PCP Reviews.

4.1.2 Person-Centred Plans

Person-Centred Planning has been used in EVE for many years and is about planning with the individual, rather than for them – the individual leads out on this process. It’s an approach that considers what’s important to them now, what they want for the future and the support required to get them there. This can be achieved with a team or circle of people to support them, including supporters and professionals.

During the Discovery Phase, the individual will complete their initial PCP based on discussions between themselves, their key worker and other supporters if they wish to invite them. Their HUB schedule and timetable will then be developed based on the goals they have identified in the PCP.

Further PCP meetings will occur every six months. The PCP will also be guided by the participant’s key working meetings, WRAP® plan and Recovery Action Plan (RCI), where relevant.

4.1.3 Wellness Plan

Participants will be given the option of completing a Recovery Action Plan during the Discovery Phase. Key workers can support the individual to complete their Recovery Action Plan if they wish. Key workers must give the participant sufficient time to complete their recovery plan prior to their next PCP meeting in order for some or all of their recovery goals to be incorporated into their PCP.

4.1.4 Person-Centred Reviews

A Person-Centred Review uses personcentred thinking approaches to explore what is happening from the person and other people’s perspectives. The review looks at what’s working and not working, what’s important to the person now and in the future and agrees outcomes for change.

The review meeting occurs annually and is facilitated by the key worker. The person attends along with people in their relationship circle/circle of support that they choose to invite.

A review meeting following a person-centred approach will:

• Ensure that everyone, including the person, has an opportunity to have their say

• Ensure there is a clear record of agreed actions

• Encourage people to add to each other’s comments

The National Framework for PersonCentred Planning is an important part of New Directions. Training for the above is mandatory for all staff working in our HUBs and can be found on HSeLanD. Additional training on the development of Personal Profiles and Person-Centred Reviews has been delivered to all staff.

Please refer to EVE’s Person-Centred Planning Standard Operational Procedure document for more information on these processes.

4.2 EASI Tool & Monitoring

The Implementation of the Interim Standards involves self-evaluation. The purpose of self-evaluation is to explore and reflect with all stakeholders (people using the service, staff and management) and to report on the effectiveness and quality of the supports being provided under New Directions.

Evaluation, Action and Service Improvement (EASI) is a self-evaluation completed by each service and is a fundamental part of a continuous quality improvement process and key to the delivery of the New Directions policy. The aim of the EASI process is to produce a constructive report which will help each service to maintain and improve the quality of its services and supports under New Directions.

Each centre will continually review their EASI Tool and action plan and update and submit to the National Office for November of each year. A process needs to be agreed and implemented to review progress and give feedback by the participants, staff and managers throughout the year.

In 2021, there were a number of webinars developed to support service providers to continue to implement the EASI continuous quality improvement process, these are available on HSeLanD. It is mandatory for all staff to complete the training and watch the webinars for the EASI Tool.

External monitoring is scheduled for implementation in 2025 and will focus on the individuals’ person-centred plan outcomes and progression.

4.3 Quality

Assurance

(QA) Audits

Governance provides a framework which ensures that organisations are accountable and have systems in place for continuous quality improvement to safeguard high standards of service provision. The QA Audit (along with the EASI Tool etc.) is in place to meet this requirement.

The self-assessment can measure and assess the progress of all EVE centres. Upon completion, EVE will be able to more accurately understand a centre’s stage of development and any supports required. The information gathered at each centre assessment will form the body of a ‘SelfAssessment Report’, which will highlight recommendations that each centre and the relevant management and support function in EVE can work on together to strengthen the centre in line with statutory and legislative quality standards requirements.

The Self-Assessment is submitted to the QA dept., which is reviewed, and a report will be issued based on findings. A site visit is scheduled, where needed, and a report issued based on this audit visit. A plan is then drafted by centres to include any actions which ultimately feed into each centres Service Plan.

4.4 Record Retention

All records for an individual must be maintained in soft copy and stored on the server, which is encrypted. These include the key worker record, Personal Profile, PCPs, Person-Centred Reviews, PersonCentred Thinking tool records, Tracker etc.

The above records will be securely maintained as per the EVE Record Retention protocols. This is in line with the HSE Record Retention policy.

4.5 Social Payments

Payments for social activities carried out during the HUB programme can be a mix a centre payments and payments made by the individual themselves. Activities that are related to personal-goals, e.g. travel training, budgeting etc. may be covered by the centre via the procurement card. Further information in relation to the procedures for this is covered in the Community Activities Protocol document which was updated in 2024.

Summary & Conclusion

5. Summary

5.1 Programme Overview

• The HUB programme is designed to support individuals with intellectual disabilities, mental health difficulties and/ or autistic people.

• It is a person-led and trauma-informed programme using a universal design approach.

• It focuses on community integration, personal development, and recovery.

• Activities are tailored to individual needs and goals, encouraging curiosity and hope.

• The programme operates through a hub-and-spokes model, connecting participants to community resources.

• Key components include Discovery Phase, Life Skills, CATCH, PATH, LINK with Transition Planning interwoven throughout.

5.2 Objectives

• Empower individuals using a strengthsbased approach.

• Encourage active citizenship and community participation.

• Create an environment supportive of recovery.

• Bridge the gap between the programme and the community.

• Maximize independence and social inclusion.

5.3 Programme Details

• Discovery Phase helps participants get acquainted with the programme, develop their Personal Profile and set initial goals.

• Life Skills focus on developing abilities for independent living and personal growth.

• CATCH (Community Access & Training for Continued Health) promotes meaningful community integration.

• PATH (Participant Alliance through the HUB) offers peer-led clubs and activities. E.g. Connect Café, Rep Group etc.

• Link provides ongoing engagement for past participants through social events and short courses.

• Transition Planning, interwoven throughout, ensures smooth progression from the programme to community involvement.

5.4 Additional Features

• Outreach Support maintains contact with participants outside the centre.

• In Reach support maintains a link between the individual and the centre.

• Hybrid programmes offer flexibility and adaptability.

5.5 Timeframe and Methodology

• Timetables developed from the PCPs –individual supports/needs

• Evaluations every 17 weeks to assess impact and progress.

• Person-Centred Plans developed every six months.

• Recovery Action Plans available to align with personal goals.

5.6 Staff Roles

• Act as key workers, supporting choice and community integration.

• Deliver educational sessions and facilitate skill development.

• Engage with community resources and promote participant autonomy.

5.7 Record Retention and Social Payments

• Records maintained securely as per EVE Record Retention Protocols.

• Social activity payments as outlined in the EVE Community Activities Protocols.

6. Conclusion

The focus of the HUB programme is to provide the participant with support, activities and community opportunities that help people to live as independently as they can and be a part of their own community to the best of their ability. The recoveryoriented HUB programme will facilitate the needs of participants, as required, through a community integration focus and recovery approach which adopts the attitudes of hope, respect and empathy towards people with mental health difficulties, intellectual disability, and autistic people (where relevant).

HUB & SPOKES MODEL

The programme will operate using a HUB and Spokes model in which the centre will act as a hub to form active and dynamic relationships (spokes) with different community-based services and resources, as depicted below.

The centre/staff will help facilitate and assist participants to form support systems and to fully participate in community living. Community based activities will run alongside those of centre-based activities over a 39hour week (pro rata based on personal-need and agreed hours).

1. SUPPORTERS

Connecting with families, friends & supporters to enhance connection and partnership working.

2. EMPLOYMENT

Links to help local employers, employability, IPS etc. to support job preperation and readiness.

3. EDUCATION

Links with local community groups, colleges, schools to build partnerships and offer courses onsite and offsite.

4. COMMUNITY

Links with local community groups, and area networks etc. for partnership working opportunities.

5. HEALTH SERVICES

Partnerships with social prescribers, GPs, clinics, Primary Care etc. to support collaborative working opportunities.

Section 7 Bibliography

7. Bibliography

• Bond et.al (2004) How Evidence-Based Practices Contribute to Community Integration. Community Mental Health Journal. December 2004, Volume 40, Issue 6, pp 569–588

• Cole, A., et al. (2007) SCIE Knowledge review 14: Having a good day? A study of community-based day activities for people with learning disabilities. University of Bristol

• Copeland, M. (1997) Wellness Recovery Action Plan® (WRAP®) (Revised 2000). Berkeley, CA: Peach Press.

• Corring, D. & Cook, J. (2006). Ask, Listen and Learn: What Clients with a Mental Illness Can Teach You about Client-Centred Practice. Client-centred practice in occupational therapy: a guide to implementation, 2nd edition. Oxford, UK: Elsevier Ltd.

• Deegan, P.E. (2004). Rethinking Rehabilitation: Freedom. Study of Current Rehabilitation, 121, 12, 5–10.

• Deegan, P.E. (2005). Recovery as a journey of the heart. In L. Davidson, C Harding & L Spaniol (Eds.), Recovery from severe mental illnesses: Research Evidence and Implications, Center for Psychiatric Rehabilitation, Boston University: Boston MA. p. 57–68.

• Deegan, P.E. & Drake, R.E. (2006). Shared decision-making and medication management in the recovery process. Psychiatric Services, 57, 11, 1636–1639.

• Department of Health & Children (2001) Quality and Fairness: A Health System for You. Dublin: Stationery Office.

• Department of Health & Children (2006) A Vision for Change. Report of the Expert Group on Mental Health Policy. Dublin: Stationery Office.

• Department of Health & Children (2020) Sharing the Vision – a Mental Health Policy for Everyone. Dublin: Stationary Office.

• Drake, R.E., Deegan, P.E., & Rapp, C. (2010). The promise of shared decision making in mental health. Psychiatric Rehabilitation Journal, 34(1):7–13.

• Expert Group on Mental Health Policy (2004a) Speaking Your Mind. A Report on the Public Consultation Process. Department of Health and Children.

• Expert Group on Mental Health Policy (2004b) What We Heard. A Report on the Service User Consultation Process. Department of Health and Children.

• Farkas, M. & Anthony, W. (2001) Overview of Psychiatric Rehabilitation Education: Concepts of Training and Skill Development. Rehabilitation Education, Vol. 15, No. 2, pp. 119-132.

• Government of Ireland (2006) A Vision for Change. Report of the Expert Group on Mental Health Policy.

• Health Service Executive (2012) New Directions Review of HSE Day Services and

Implementation Plan 2012-2016. Personal Support Services for Adults with Disabilities. Working Group Report. Dublin: HSE.

• International Association of Psychosocial Rehabilitation Services (IAPSRS). (2000) Core Principles of Psychiatric Rehabilitation. PSR Nova Scotia.

• Mental Health Commission (2005a) Quality in Mental Health – Your Views. Report on Stakeholder Consultation on Quality in Mental Health Services. Dublin: Mental Health Commission.

• Mental Health Commission (2008) A Recovery Approach within the Irish Mental Health Services. A Framework for Development. Dublin.

• Sharing the Vision, HSE, Dublin 2020

• National Disability Authority (2005) Good Practice Guide on Partnership with People with Experience of Mental Health Difficulties. Dublin: National Disability Authority 29.

• NSUE (2011) Second Opinions. Summary Report of the NSUE Survey of Members on Vision for Change. Dublin.

• NSUE (2012) Second Opinions. Summary Report of the NSUE Survey of Members on Vision for Change. Dublin.

• NSUE (2012) Second Opinions. Report of the NSUE Survey of Irish Mental Health Services by Service Users, their Family Members and Friends. Dublin.

• Rankin, J. (2005) Mental health and social inclusion. London: Institute for Public Policy Research.

• Rapp, C.A. (1996) The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness. Oxford University Press

• Rapp, C.A. & Goscha, R.J. (2006) The Strengths Model. Oxford University Press.

• Repper, J. & Perkins, R. (2003) Social Inclusion and Recovery. Edinburgh: Baillière Tindall

• Simons, K. & Watson, D. The View From Arthur’s Seat. Review of services for people with Learning Disabilities – A literature review of housing and support options beyond Scotland. Edinburgh: Scottish Executive Central Research Unit.

• Slade, M. (2009) Personal Recovery & Mental Illness. A Guide for Mental Health Professionals. Cambridge University Press.

• Social Exclusion Unit (2004) Mental health and social exclusion. London: Office of the Deputy Prime Minister.

• Snow, J. (1998) What’s Really Worth Doing/From Behind the Piano. Inclusion Press.

Section 8 Appendices

8. Appendices

Appendix 8.1 – Staff Role outline

In order to deliver a comprehensive HUB programme an example (not exhaustive and will be reviewed continually based on organisational/national policies and strategies) of the staff’s role (under programme headings) will cover the following:

Staff Role - Life Skills

• Plan & implement modules around the development of skills necessary for each participant regarding ‘connecting to their community’ in relation to their specific needs.

• Deliver appropriate informational modules/sessions on areas of need.

• Co-facilitate sessions with participants and or persons who have completed the co-facilitation training.

• Provide, facilitate and/or source educational modules.

• Provide, facilitate and/or source basic skills development modules (e.g. money management, literacy, numeracy, managing anxiety, decision making, sexuality & relationships etc.) in community/centre/HUB settings, where relevant.

• Support peer-sharing activities and participant involvement.

• Provide/maintain recovery perspective.

• Provide information and support to allow

participants to maintain their physical health (e.g. discuss healthy diets and exercises).

• Encourage and support participants in recovery to start peer-support groups (e.g. smoking cessation support group) at the base location and provide resources to ensure the long-term success and independence of such groups.

• Organise and coordinate (alongside participants) activities and social programme services at base/multiple HUB locations in the community/EVE network.

• Maintain records (as for all programmes/ interventions).

Staff Role - CATCH

• Liaise closely with mainstream services, other specialist agencies and wider community to build a joint approach to facilitating community inclusion and participation and active citizenship.

• Invite community leaders to the HUB and educate them in the service that is being provided by the HUB.

• Build expertise in community development approaches through liaising with local partnerships/groups/ associations/initiatives.

• Facilitate access to mainstream education programmes, where possible.

• Provide, with prior consent, strong links between home life and other support

services to offer the participant a coordinated approach to developing independence.

• Provide/facilitate family support education sessions2, i.e. invite guest speakers in to give a talk on a specific area and invite family members to attend/participate.

• Develop and maintain links to access primary care services.

• Develop and maintain links with multidisciplinary teams.

• Form links with community health promotion officers and local agencies involved in health & wellbeing.

• Develop and maintain links with bridging programmes to access basic workrelated skills which can be further developed in vocational training programmes.

• Assist with accessing vocational information and vocational guidance.

• Identify a range of vocational support services the participant might need –assist the participant with putting these in place.

• Create and maintain links access to therapeutic occupational activities on a regular basis.

• Assist with ‘tapping’ into and participating in community opportunities for creative expression/creativity.

• Endeavour to facilitate access to psychological and social therapies.

• Develop links with mainstream community agencies.

• Assist / link the participant with the relevant service in relation to obtaining

benefits, budgeting, child minding, travel pass etc.

• Develop links to establish and develop employment support.

• Develop local connections through linking in with local statutory and voluntary service providers and support networks to support community integration.

• Assist/support participants linking in with agencies that assist in finding and maintaining housing in the communities they wish to live in and that meet their interests via local housing authorities, housing associations, etc.

• Provide support, encouragement and guidance for participants to pursue additional education.

• Provide information on volunteer opportunities and encouraging participants to be aware of community issues and voting.

• Facilitate the development of networks/ circles of support around the participant, where they wish.

• Learn about community resources that are available to persons in recovery. Encourage people to utilise these resources.

• Develop reciprocal relationships with community businesses, educational institutions, recreational organisations, and other entities.

• Link participants to vocational assistance, job training, and job placement services.

• Support the re-establishment of meaningful employment.

2 Provide (via external speakers/professionals etc.) family members, caregivers, and friends with the tools necessary to participate in the recovery process of a loved one. Family members learn about mental illness, develop effective coping strategies, and discover community resources. Consent may be required, please link in with Slánú.

Staff Role - LINK

• Run LINK community update session weekly, where timetabled.

• Encourage and assist participants to take part in recreational and physical activities.

• Plan and administer regular programmes and special events.

• Assist with the Wellness Café activities.

• Provide ongoing support, where possible, to participants who progress further into the community and do not actively attend the HUB on a regular basis to reduce social isolation.

• Promote peer-networks for past and present participants.

• Facilitate committee meetings and assist and support any committee groups that may be informed by the HUB.

• Contribute to planning and policy development for programme activities and participant involvement.

Staff Role – Outreach Support

• Ensure that all applicants who are referred to the service are supported through all stages of the referral procedure necessitating inreach and outreach contact.

• Provide a LINK to the service when an absence has been noted for more than two days, for example, telephone contact (with prior permission). Ref: Consent form

• Provide support and outreach to participants who are not able to attend.

• Provide accessible, timely information when needed.

• Support and encourage participants when they are unwell, in hospital etc. by sending cards and making phone contact (i.e. outreach).

Staff Role – PATH3

• Oversee the preparation of Signage, Posters, Risk Assessments as required.

• Research the details of the events, transport, times etc. and notify the people signed up of the plans as required.

Staff Role: Youth Group / Beginnings

• Assist participants gain life skills such as decision making, problem solving, self-responsibility, accountability, communication, goal setting, citizenship, caring relationships, leadership, healthy lifestyle choices and career exploration skills in project work.

• Encourage youth leadership through committees, demonstrations and individual guidance.

• Encourage participants to learn & experiment with new ideas, techniques & skills.

• Offering positive and constructive feedback to the participants.

• Inform and encourage participants to actively participate in programme opportunities that interest them.

• Plan and administer regular programmes and special events for the youth group.

• Provide supervision.

• Ability to encourage participants to “doit-yourself”.

3 Some groups are peer-led (e.g. cinema club, knitting club etc.) and others may be staff facilitated (e.g. Book Club etc.). This should be peer-led and/or co-produced where possible. The individuals may need support at the beginning but this can be tapered off.

Staff Role – Key Worker

• Work collaboratively with staff team, service users and community/service support network at all times.

• Provide and support one-to-one mentoring with the participant.

• Assist with making choices and planning.

• Develop and monitor individualised programme of supports with each participant.

• Support participants with transition from the HUB to their local community (transition planning/progression).

• Challenge, encourage and support participants to try new experiences and do new things in their lives on an ongoing basis.

• Develop, encourage & facilitate risk assessments and positive risk taking.

• Work collaboratively with other support services (residential, respite, community services etc.) in order to maximise potential to deliver person-centred social and personal development goals.

• Explore social roles with participant.

• Engender a team working and partnership approach.

• Facilitate access to advocacy services.

• Respond to needs of participants –Person-Centred Plans (PCP’s)/ Recovery Action Plans and Person-Centred Reviews.

• Establish effective relationships with participants and respond to boundary issues in a timely manner

• Encourage and assist participants with developing relationships and making friends with other persons in recovery and individuals in the community.

• Develop and maintain Personal Profiles, PCPs/Recovery Action Plans etc.

Forms

Appendix 8.2 – LINK Contact Form –Special Events/Social

HUB Link Contact Form (Special Events / Socials)

EVE XX LINK Contact Form (Special Events/Link Session)

Please complete this form prior to your exit from the programme if you wish to be contacted in relation to activities offered through our Link programme:

Please complete this form prior to your exit from the programme if you wish to be contacted in relation to activities offered through our Link programme:

Please fill in the form using BLOCK LETTERS.

Name:

Personal Details:

Participant Name:

Address:

Participant Address:

Participant Phone Number:

Home Telephone:

Participant Email Address:

Mobile Phone:

Participants preferred method of contact: (please tick)

Email Address:

Email ☐ Phone call ☐

Preferred method of contact: (please tick)

Text ☐

Email: Home Phone call: Mobile Phone call: Text:

Permission to contact

Permission to contact:

I agree to my details being kept on file for the purpose of contacting me to discuss courses/activities that may be of interest to me through the LINK programme:

I agree to my details being kept on file for the purpose of contacting me to discuss courses / activities that may be of interest to me through the LINK programme:

Name:

Signed:

Signature:

Date:

Date:

Appendix 8.3 – LINK Short Course Booking Form – Participant

EVE Short Course Booking Form

EVE XXX LINK Short Course Booking Form

EVE is part of the HSE and offers a range of services for adults living with mental health challenges, adults with an intellectual disability and autistic adults We provide health and wellbeing supports, opportunities to develop skills, ways to connect with the community and support to achieve personal goals. We aim to support you as you live the life of your choosing.

Course 1

Date:

If you are interested in applying for a short course, please complete all sections of the form and return it to us

Course 2

Date:

Please fill in the form using BLOCK LETTERS We can support you to fill in this form if you wish

Course 1

Course 3

Course 2

Name:

Course 3

Date of Birth:

Part 1: Your Contact Details

Location:

Date:

Location:

Location:

Name: Email:

Address:

Address:

Phone Number:

Email Address:

How would you prefer to be contacted? (Please tick)

Home Telephone:

Phone ☐ Email ☐ Text ☐ Other ☐

Mobile Phone:

Is there anything that could affect your attendance/participation?

How would you prefer to be contacted? (please tick)

Part 2: Your Support Needs:

Phone Email Text Post Other?

Person to contact in an emergency:

Name: Phone No.:

Is there anything that could affect your attendance/participation?

Relationship to you:

Email:

Do you have any specific learning needs we should know about? (Please state)

Medical

Do you have any personal health information (physical or mental) that would be helpful for us to be aware of?

Do you have any medical information we should know about? (Please state)

Anything else you would like us to be aware of to help support you better?

Emergency contact or GP details:

Applicant’s signature:

Date:

Who should we contact in the event of an emergency (if GP details given above)?

Please send this completed booking for m to the location you want to attend. Please scan to find HUB

Locations and their contact details:

Learning

Do you have any specific learning needs we should know about? (Please state)

Anything else you would like us to be aware of?

Confirmation of your place wherever possible will be made by phone or email and if you have any questions please get in touch

Information contained in this booking form is kept confidential It is used to support the effective administration and management of the centre's programmes and services.

Applicant’s signature:

Date:

Please send this completed booking form to:

Alternatively telephone/email:

Confirmation of your place wherever possible will be made by post or email and if you have any questions please get in touch. (Information contained in this booking form is to be kept confidential and secure by EVE. It will assist with the monitoring and management of the Centre – by understanding how many people use the Centre and for what course, we can work to improve what is offered.)

Appendix 8.4 – LINK Enrolment

Referral Form from CMHN/Mental Health Team Contact Person

HUB Link Enrolment Referral (Mental Health Team Contact Person)

EVE is part of the HSE and offers a range of services for adults living with mental health challenges, adults with an intellectual disability and autistic adults. We provide health and wellbeing supports, opportunities to develop skills, ways to connect with the community and support to achieve personal goals We aim to support you as you live the life of your choosing

Link Enrolment referral (CMHN / Mental Health Team Contact Person)

If you are interested in applying on behalf of an individual who would like to access the HUB Link programme, please complete all sections of the form and return it to us.

Applicant Name:

Please fill in the form using BLOCK LETTERS.

Applicant Address:

Applicant Name:

Applicant Address:

Applicant Date of Birth:

Applicant Phone Number:

Applicant DOB:

Applicant Email Address:

Applicant’s Email Address:

Consultant’s name:

Consultant’s Name:

Applicant’s Phone Number:

GP contact number: Clinic:

Your professional role with the applicant:

GP Contact Number: Clinic:

Reasons for the referral?

Your relationship to the applicant:

1. Reasons for referral?

Is there any relevant information we should know about this person that could impact on their engagement in the Link programme or the wider learner community?

2. Is there any relevant information we should know about this person that could impact on their attendance and engagement in the LINK programme?

Signed: Date:

Email:

Signed:

Role:

Date:

Appendix 8.5 –Outreach Consent From

EVE XX HUB Outreach Consent Form

Participant Name Keyworker:

In EVE XX we have an outreach programme that involves an agreement with you about when to contact you and who to contact, if needed. If we have not heard from you in (please tick):

1 day 2 days 3 days Other:

We will:

Phone you

Text you

Number inserted here:

Number inserted here:

Email you Email address inserted here:

Write to you

Address inserted here:

If we have not got a response from you from any of the above, we will contact:

Your preferred first point of contact Name & number:

Your medical team Name & clinic:

Your preferred second contact person Name & number:

I understand and agree with the above information.

Participant signature:

Date:

Witness signature:

Date:

HUB Model