Key Worker Service

Autism West Midlands Keyworker Service.

Autism West Midlands are working in partnership with Birmingham and Solihull Mental Health NHS Foundation Trust to deliver a Key Worker service for autistic adults who are over the age of (25+) who have mental health needs and are at risk of hospital admission or require additional support during discharge from mental health inpatient services.

The Key Worker Service can work with individuals for an estimated 12-week period, alongside mental health teams to ensure autism specific support is in place to achieve best outcomes for autistic individuals.

Service Objectives

  • To address the challenges that autistic adults face whilst navigating mental health services.
  • To focus on autistic needs to better enable successful outcomes for people.
  • Work alongside mental health services focusing on autistic needs to help avoid hospital admissions and remain engaged with community support/treatment.
  • To encourage better engagement with treatment through helping autistic individuals establish connections and relationships with medical professionals
  • To build collaborative working so staff understand the autistic persons needs better and provide effective person-centred support
  • To increase knowledge and skills within mental health teams of autism to encourage and establish co-production

Keyworkers can offer

  • Help to implement neuro affirming communication and Autism specific plans such as communication passports, health action plans, sensory profiles, crisis plans
  • Prevention of health inequalities, ensuring a person has fair access to health services such as health checks, medication reviews and promote access to specialist services
  • Support it remove barriers and assist in implementing reasonable adjustments
  • Provide advice and guidance to help prevent a person reaching mental health crisis
  • Help to give people a voice to have their needs met and their care and support adjusted effectively
  • Support autistic individuals to transition from inpatient services back into the community and establish longer term support pathways
  • Provide advice and guidance on developing a support network to prevent isolation and social barriers.

What we can’t offer

We are not a care service/provider – We cannot offer care services such as personal care or personal assistant support to access the community.

Keyworkers are not trained mental health clinicians and cannot administer medications or certified therapeutic interventions.

Eligibility criteria to access the service

A professional must refer an individual we do not accept referrals directly from individuals

A person needs to have an Autism diagnosis to access support from this service

The autistic individual needs to be registered on the Dynamic Support Register (DSR) to access support from this service

What is the Dynamic Support Register (DSR) – The DSR aims to prevent inappropriate admissions to mental health hospitals by identifying individuals who need extra support to manage their needs in the community. The register focuses on people with learning disabilities and/or autism who are vulnerable to hospital admission due to a lack of adequate support. The DSR is a database that brings together various agencies and services involved in providing care and support. Professionals use the register to track individuals’ needs, identify potential risks, and coordinate support plans. The DSR uses a color-coded system (Red, Amber, Green, Blue) to indicate the level of risk of hospital admission for each individual. 

  • Red: Immediate risk of hospital admission. 
  • Amber: High risk of hospital admission without timely support. 
  • Green: Risks are being well-managed in the community. 
  • Blue: Individual is already in a mental health hospital. 

Dynamic: The DSR is called “dynamic” because the level of risk (and the corresponding colour code) can change as a person’s situation and support needs evolve it also facilitates communication and information sharing between different professionals and agencies involved in a person’s care. The DSR is a key component in Care (Education) and Treatment Reviews (C(E)TR), which are used to develop and review care plans for individuals with learning disabilities and autism. 

Referral pathway We can only accept referrals to this service from professionals for an individual. To refer to us or for more information please email [email protected] or call 0121 450 7582