Community Enhanced Rehabilitation Team (CERT)

A person may be eligible for community mental health enhanced rehabilitation when they:

• Are currently placed in independent or NHS provider hospitals, in or out of area and are ready for community rehabilitation
• Live in highly supported (24 hour staffed) accommodation
• Need community rehab or intensive home rehab from our acute or community mental health teams.

CERT can provide second opinion consultation and assessment on complex case presentations.

CERT operates using a holistic, patient centred clinical model designed to address multiple aspects of recovery and wellbeing. By integrating key therapeutic frameworks, the CERT model ensures comprehensive care, tailored to individual needs.

CERT will have a whole team culture to care influenced by:

• Biopsychosocial: a holistic approach to mental health and wellbeing
• Open dialogue: encouraging open and honest communication to support shared understanding and decision making
• Good clinical management: structured, organised, reliable, multidisciplinary approach to care 
• Mentalising clinical stance: a stance of curiosity that focuses on understanding the impact of trauma, psychological, attachment factors on how we understand our own mind and the assumptions we make about others’ minds.

At the consultation, information is gathered by you and wider social networks involved in your care; taking into consideration your rehabilitation goals; mental health needs and a brief description of issues, risk or vulnerabilities, any additional needs, safeguarding history and understanding if any other services are involved in your care.

We also check our secure online database for any further, relevant information.

If we feel that support from our team may not be appropriate, we will try to offer advice and share details of other services. If we feel, from the information provided, that support may be appropriate, an assessment is offered.

During an assessment, we try to understand what is going on for you at that moment and how we might help. We will cover:

• Mental health symptoms and experiences
• Thoughts, feelings and behaviours
• Goals and aspirations 
• What gives you a sense of belonging and enjoyment
• Physical health and wellbeing
• Social and family relationships.

CERT draws on a holistic view of mental health and recovery. The team includes:

• Lived experience practitioners
• Support workers 
• Social worker
• Mental health nurses
• Clinical psychologist
• Occupational therapist
• Psychiatrist
• Registered general nurse.

Your interventions will be developed and formed with you at the centre of your care; and specifically working with those in CERT, who are best suited to the specific interventions, including the therapeutic relationship.

Interventions will be goal and time specific. We will ensure clear communication and an overview of time scales and how we can review progress of your journey.

This will be developed using a personalised care plan, including the whole version of you and what is important. Some interventions which may be offered include:

• Graded exposure in the community
• Daily skill development
• Sensory strategies
• Relapse prevention work booklet
• Money management
• Transport support
• Medication education
• Healthy lifestyle and wellbeing
• Communication passport and strategies
• Interpersonal skills
• Family involvement.

Whenever possible, CERT will want to link in and work with your family and carers to ensure we all work together to support your recovery journey.

All information that is discussed will remain confidential, unless we believe something that has been shared puts a child or someone else at risk.

In this instance, we would have to share this information with other relevant agencies. When we do this, we will always try to discuss this with you first.

Your care is yours, therefore we will obtain your consent before speaking with family or your social networks, so we can work collaboratively on your journey in the community.

The information gathered is added to an assessment letter, which is copied to your care team and GP. This information is input into our secure, internal patient record system.