Home Focus

1. Introduction

Version followed: West Cork Home Focus as described by its operator, the National Learning Network (NLN, Rehab Group), in its 2021 service brief, plus the HSE listing of the 2008 UCC evaluation Having Choices and local press accounts (2020–2021). The WHO 2021 technical package Community outreach mental health services profiles Home Focus in section 2.3; nothing below is taken from that section or from the full Having Choices report [uncertain]. No published step-by-step protocol exists, so most procedural steps below are the writer's synthesis and are marked [synthesis].

What it is. Home Focus is not a therapy and has no treatment manual. It is a small, non-clinical, rights-based outreach and recovery-support service in dispersed rural West Cork, Ireland, based at NLN Bantry. It began in 2006 as a pilot run by six partner organisations (NLN West Cork, West Cork Mental Health Services, the Irish Advocacy Network, HSE Disability Guidance Services, Work Start West Cork and West Cork Community Partnership), first funded by the Department of Justice, Equality and Law Reform via Pobal, and is now funded by the HSE. It works with people with mental health difficulties who are isolated from centre-based services by distance and poor transport, or who cannot or will not use those services, and with their families. A mixed team of mental health, vocational and lived-experience staff meets people at home, in the community, or by phone and text, and helps them reach community, training, education and employment opportunities. In 2021 the WHO listed it as one of 25 good-practice examples of community mental health services worldwide. [source: NLN service brief 2021; HSE Having Choices page; Southern Star 2020, 2021]

How change is thought to happen. Change comes from a reliable, unhurried relationship with workers who go to the person, follow the person's own stated needs instead of directing them, and accompany them step by step back into ordinary community life. That life includes social networks, skills, practical affairs, courses and work. Recovery is framed as growth and as finding one's own answers, not as symptom treatment. [source: Southern Star 2020, 2021; NLN brief 2021]

Who this guide is for. A clinician (community mental health nurse, psychologist, psychiatrist, OT, social worker or therapist) who refers to Home Focus, works in the team, or wants to set up a similar rural outreach service. Procedural detail below the level the sources give is marked [synthesis].

2. Framework

Service parameters (published). [source: NLN brief 2021 unless stated]

• Hours: 9am–5pm, five days a week. It is not a crisis or out-of-hours service.
• Duration of support: 3 to 18 months per person.
• Capacity: funded for up to 34 people at a time; about 23 new people a year. In 2020 a team of five was supporting 27 people [source: Southern Star 2020].
• Cost: about €260,000 a year (roughly €7,600 per person), free to the person.
• Referral: all referrals come through the (HSE) Mental Health Service, and local community mental health nurses form part of the support network [source: Southern Star 2020].
• Team (as listed in 2021): one full-time community mental health nurse (Clinical Nurse Specialist), two half-time Rehabilitative Training Instructors, one part-time Recovery Support Worker and one full-time Recovery and Development Advocate. Peer support is built into the team structure. Area managers at NLN Bantry oversee the service. [source: NLN brief 2021; WHO guidance acknowledgements via medbox copy]
• Position in the system: the service complements West Cork Mental Health Services. NLN presents it as matching the "stepped care" approach of the national policy Sharing the Vision.
• Formats: one-to-one home visits, meetings in community settings (e.g. a café), phone calls and text messages, chosen to suit the person's needs and comfort at the time [source: Southern Star 2020].

Phases. The sources describe no formal phases or criteria for moving between them [uncertain]. The working sequence below is my reconstruction from the published aims, duration and referral route [synthesis]:

Aims the service publishes (use them as the outcome domains for a person's plan): mental health and wellbeing; independent living skills; community connection; access to training, education and employment; quality of life; future planning [source: NLN brief 2021]. Press accounts add two system aims: fewer admissions and readmissions to high-support psychiatric units, and less rural isolation [source: Southern Star 2021].

3. Guiding principles

[source: NLN brief 2021; Southern Star 2020, 2021; rehab.ie WHO recognition page, unless marked]

• Recovery philosophy. Recovery is possible and is about growth. In practice: hold hope openly, and measure progress by the person's life, not by symptoms alone.
• Human rights agenda. WHO picked the service as an example of rights-based provision. In practice: the person keeps decision-making authority over their own support.
• Non-coercion and autonomy. The WHO guidance that features the service calls for services without coercion that promote autonomy and inclusion [source: NLN brief 2021, summarising WHO]. In practice: participation is voluntary. No pressure, no conditions, no threat of reporting to make someone engage.
• Do not direct; let people voice their needs. In a staff member's words: "We try never to direct but to let people voice their own needs" [source: Southern Star 2020]. In practice: ask before suggesting, and follow the person's agenda.
• With, not for. Staff "work with people rather than for people" [source: Southern Star 2021]. In practice: do tasks alongside the person, not on their behalf, unless they ask.
• People find their own answers. In practice: help the person think and choose, and hold back expert solutions.
• People first, non-medical. The ethos is people-first and the service is non-medical [source: Southern Star 2020]. In practice: no diagnosis-led agenda. Clinical matters go back to the mental health team.
• Time, practicality, reliability, flexibility. The service stresses "giving people time and being practical, reliable, and flexible" [source: rehab.ie]. In practice: turn up when you said you would, allow long visits when needed, and help with real-world tasks.
• Reliability as a therapeutic ingredient. A service user in the 2008 evaluation valued staff being "good to their word", and said they would spend two or three hours if needed [source: NLN brief 2021 quoting Having Choices]. In practice: never cancel lightly, and keep promises small enough to keep.
• Go to the person. The service exists for people cut off by geography and transport. In practice: meet at home or wherever the person is comfortable, and use phone and text between visits.
• Lived experience inside the team. Peer support is built into the staffing, and WHO stresses lived-experience involvement in development, delivery and monitoring. In practice: peer roles are core staff, and service users shape the service.
• Community orientation and inclusion. In practice: aim every activity at ordinary community settings, groups and services, not at a service-only world.
• Low visibility. A manager credits much of the service's success to its "invisibility", meaning staff blend into the community [source: Southern Star 2021]. In practice: unmarked cars, ordinary venues, and no visible "mental health" labelling in public.
• Strengths-based. Staff help people identify their strengths [source: Southern Star 2020]. In practice: start from what the person can do and has done.
• Stepped care and partnership. The service complements the statutory team. In practice: share information with the person's consent and know when to step support up or down.
• Families included. Support is offered to individuals and their families [source: NLN brief 2021]. In practice: involve family when the person wants it, and offer them information and contact.
• Time-limited and forward-looking. Support lasts 3–18 months with future planning as an explicit aim. In practice: talk about the ending and what comes next from early on [synthesis on timing].

4. Intervention inventory

The published sources name what Home Focus does (home visits, community meetings, phone and text, accompaniment, social networks, skills, appointments, activities, MABS applications, café visits, linking to training, education and employment, peer support, family support). They give no step-by-step procedure. Each entry below therefore states its source for the what, and marks the how as [synthesis]: my own practical guidance, consistent with the stated principles. No manual exists to check it against. All example language is illustrative.

4.1 Referral and fit check (for the referring clinician)

• Purpose / when: To get the right people into a small, time-limited outreach service. All referrals come via the Mental Health Service [source: Southern Star 2020]. The target group is people with mental health difficulties isolated from centre-based services by rural distance and poor transport, and their families [source: NLN brief 2021; HSE page]. Formal criteria are not published [uncertain].
• Steps [synthesis]: (1) Check the person lives in the West Cork catchment and is linked to the mental health service. (2) Check that isolation or access is the barrier (distance, transport, anxiety about leaving home, loss of social contact). (3) Ask the person whether they would like someone to visit and help with goals of their own choosing. Refer only with their agreement. (4) Send a short referral covering current supports, risk summary, preferred contact method, what the person says they want, and family involvement wishes. (5) Make clear what Home Focus is not: crisis cover, out-of-hours, or medication monitoring.
• Example language (illustrative): "There's a small team based in Bantry who'll come out to you. They don't do treatment. They help with whatever you'd like to get going again, like getting out more, a course, sorting out bills. It's up to you whether you want them."
• Watch for: Referrals made to "get someone to keep an eye on" a person, or to secure compliance. That conflicts with the non-coercive ethos. Send active crisis or high acute risk back to the clinical team first.

4.2 First contact and engagement visit

• Purpose / when: Begin a relationship on the person's terms. Staff build a relationship with each person [source: Southern Star 2021].
• Steps [synthesis]: (1) Arrange the visit by the person's preferred method and place. Offer home, a neutral community venue, or a phone call first. (2) Arrive on time, introduce your role plainly (including any lived-experience role, if you choose to share it), and say how long you can stay. (3) Explain the service: voluntary, free, weekday hours, 3–18 months, the person decides the focus [source for parameters: NLN brief 2021]. (4) Spend most of the visit listening. Do not open with assessment forms. (5) Agree the next contact before leaving, and keep it.
• Example language (illustrative): "I'm not here to assess you or tell you what to do. I'd like to hear how things are and what, if anything, you'd like to be different."
• Watch for: Polite agreement without real interest. Check what the person actually wants. It is working when the person is at home or answers at the agreed time, and starts raising topics themselves.

4.3 Choosing the contact format

• Purpose / when: Match contact to the person's need and comfort at that time. Formats are home visits, community settings, phone calls and texts [source: Southern Star 2020].
• Steps [synthesis]: (1) Ask each time which format suits. (2) Use texts for reminders and short check-ins between visits. (3) Move meetings from home to community venues as the person's confidence grows. (4) Allow long visits when a problem needs sorting. A service user described staff staying two or three hours if needed [source: NLN brief 2021 quoting Having Choices].
• Example language (illustrative): "Would you rather I call up to the house Thursday, or meet in town for a coffee?"
• Watch for: Getting stuck in home-only contact when the person's goals point outward.

4.4 Hearing the person's own needs and goals (person-led planning)

• Purpose / when: The core stance from the first weeks on. Staff listen to what matters to the person and support them towards their goals, and "let people voice their own needs" [source: Southern Star 2020, 2021].
• Steps [synthesis]: (1) Ask open questions about a good day, what has been lost, and what the person would like back. (2) Write goals in the person's words, across the published aim domains: wellbeing, living skills, community connection, training, education and employment, quality of life, future planning [source for domains: NLN brief 2021]. (3) Break each goal into small, concrete first steps the person picks. (4) Review at most visits. Let goals change. No specific planning tool (such as WRAP) is named in the sources [uncertain].
• Example language (illustrative): "If things were going a bit better in six months, what would you be doing that you're not doing now?" / "What would be a small first step, and do you want me with you for it?"
• Watch for: The worker's agenda (e.g. "you should do a course") creeping in. It is working when goals are in the person's language and steps get done.

4.5 Identifying strengths

• Purpose / when: Staff help people identify their strengths [source: Southern Star 2020]. Use this early, and again when the person is discouraged.
• Steps [synthesis]: (1) Ask about past work, skills, interests, people they have helped, and what got them through hard times. (2) Reflect strengths back with concrete evidence. (3) Link strengths to goals (e.g. a past interest in gardening points to a community garden).
• Example language (illustrative): "You kept the farm accounts for years. That's a real skill. Could it help with the form you're dreading?"
• Watch for: Empty praise. Keep strengths specific and grounded in evidence.

4.6 Practical help with everyday affairs (alongside, not for)

• Purpose / when: Sort practical barriers that keep people stuck. Published example: helping with applications to MABS, the Money Advice and Budgeting Service [source: Southern Star 2021].
• Steps [synthesis]: (1) Ask the person to show you the problem (letters, bills, forms). (2) Agree who does what, with the person doing as much as they can, in line with "work with people rather than for people" [source: Southern Star 2021]. (3) Make calls together on speakerphone and fill in forms side by side. (4) Link to the specialist service (MABS, welfare, housing) rather than becoming the specialist. (5) Follow up on the next visit.
• Example language (illustrative): "Will we ring them together? You talk and I'll be here if you get stuck."
• Watch for: The worker doing everything, which breeds dependence. It is working when the person handles the next similar task with less help.

4.7 Accompanying to appointments

• Purpose / when: Staff accompany people to appointments [source: Southern Star 2021]. Use it when transport, anxiety or past bad experiences block attendance.
• Steps [synthesis]: (1) Plan the trip together: transport, timing, what the person wants to say. (2) Agree your role in the room (silent support, prompting, or speaking only if asked). (3) Debrief afterwards: what went well, what's next. (4) Fade from going in, to waiting outside, to a phone check before and after.
• Example language (illustrative): "Do you want me in with you, or waiting outside?"
• Watch for: The worker becoming the voice. The person should lead.

4.8 Building independent living skills

• Purpose / when: A published aim [source: NLN brief 2021]. Use it when daily routines, budgeting, cooking, shopping or self-care have slipped. The Rehabilitative Training Instructor role suggests a training approach, but its methods are not described [uncertain].
• Steps [synthesis]: (1) Pick one skill the person wants. (2) Do it together in the real setting (their kitchen, the local shop). (3) Hand over parts of the task step by step. (4) Agree practice between visits, with a text check-in if wanted.
• Example language (illustrative): "Shall we do the shop together this week, and next week you do the list and I just come along?"
• Watch for: Skills taught in the abstract. Practise in the person's real setting. It is working when the routine holds between visits.

4.9 Community re-entry outings

• Purpose / when: Rebuild comfort in ordinary public places. Published example: joining someone for coffee in a café; staff also accompany people to activities [source: Southern Star 2021]. Use it when the person avoids going out or has lost confidence.
• Steps [synthesis]: (1) Choose a low-demand venue the person picks, at a quiet time. (2) Agree how long and a signal for leaving early. (3) Go together and debrief briefly. (4) Step up: busier times, longer stays, the person ordering, then going alone with a text before and after. (5) Keep staff low-key in public (no lanyards or service branding), in line with the service's "invisibility" [source: Southern Star 2021].
• Example language (illustrative): "We'll go for twenty minutes. If you want to head off earlier, just say and we'll go, no problem."
• Watch for: Overwhelm in public (see 5.3). Pushing past what the person agreed breaks the non-coercive stance. It is working when outings get longer, busier or happen without staff.

4.10 Broadening social networks and linking to community groups

• Purpose / when: Reduce isolation and connect people to their community. Staff help people broaden their social networks [source: Southern Star 2021]. Better links with community groups and support organisations were among the evaluated outcomes [source: NLN brief 2021].
• Steps [synthesis]: (1) Map the person's current contacts and past interests. (2) Research local options together (clubs, GAA, ICA, Men's Sheds, choirs, volunteering, peer support groups, adult education). (3) Visit or phone together first. (4) Attend the first session with the person if they wish, then fade out. (5) Review what the person got from it.
• Example language (illustrative): "You used to sing. There's a choir in Skibbereen on Tuesdays. Want to find out more together?"
• Watch for: Linking only to mental-health-only groups. Aim for ordinary community settings [synthesis].

4.11 Access to training and education

• Purpose / when: A core aim [source: NLN brief 2021]. One staff member calls Home Focus a training programme that helps people find their strengths and reach the training or supports they need [source: Southern Star 2020]. The two Rehabilitative Training Instructors are vocational staff [source: NLN brief 2021]. Specific courses are not named [uncertain].
• Steps [synthesis]: (1) Explore interests, past learning and barriers (transport, confidence, literacy, digital access). (2) Look at options together (NLN programmes, Education and Training Board courses, online or short courses). (3) Help with application and enrolment. Accompany the person to an open day or the first class if wanted. (4) Check in during the first weeks, and problem-solve dropping out early.
• Example language (illustrative): "What did you enjoy learning, ever? Let's see what's on locally or online that fits."
• Watch for: Overreaching first steps. Start with short, low-stakes courses.

4.12 Pathway to employment

• Purpose / when: Facilitating access to employment is a stated aim, and the team includes vocational professionals [source: NLN brief 2021]. Specific methods (e.g. Individual Placement and Support) are not described [uncertain].
• Steps [synthesis]: (1) Discuss work goals, past work and fears about welfare benefits. Link to welfare-rights advice before any change. (2) Consider volunteering or part-time work as steps if the person wants them. (3) Help with CV, applications and interview practice. (4) Link to employment services and NLN vocational programmes. (5) Offer in-work check-ins by phone or text.
• Example language (illustrative): "Would you like to talk through what work might look like for you, and what you'd need to make it manageable?"
• Watch for: Benefit traps and sudden full-time starts. Plan pace with the person.

4.13 Peer support within the team

• Purpose / when: Peer support is built into the team structure, and the service combines people with lived experience of mental health services with professional staff [source: NLN brief 2021; rehab.ie]. The Recovery Support Worker and Recovery and Development Advocate posts appear to carry this, but role descriptions were not found [uncertain].
• Steps [synthesis]: (1) Offer the person contact with a peer worker as standard, not as an add-on. (2) Peer workers share their own recovery story selectively, when it helps the person. (3) Peer workers model hope, practical coping and navigating services. (4) Peer workers take part in team decisions as equals.
• Example language (illustrative, peer worker): "I've been where you are with the services. Some things helped me, some didn't. Happy to talk about that if it's useful."
• Watch for: Peer roles used as cheap support workers. Protect the peer role and its supervision.

4.14 Advocacy and voice

• Purpose / when: The service has a full-time Recovery and Development Advocate and works with a human-rights agenda [source: NLN brief 2021; rehab.ie]. What the advocate role does in practice is not described [uncertain].
• Steps [synthesis]: (1) Help the person prepare for meetings with mental health, housing or welfare services: their questions, their preferences. (2) Support them to express treatment preferences, request reviews, or complain. (3) Refer to independent advocacy (e.g. statutory or voluntary advocacy services) where formal representation is needed.
• Example language (illustrative): "What do you want the team to hear from you at Tuesday's review? Let's write it down in your words."
• Watch for: Speaking over the person. The goal is the person's own voice.

4.15 Family support

• Purpose / when: The service supports individuals and their families [source: NLN brief 2021]. The form of family work is not described [uncertain].
• Steps [synthesis]: (1) Ask the person whether and how they want family involved. (2) With consent, meet family members to explain the service and hear their concerns. (3) Share information only as the person agrees. (4) Point family to carers' supports and information.
• Example language (illustrative): "Your mother asked how she can help. What would you like me to tell her, and what would you rather keep between us?"
• Watch for: Family pressure overriding the person's goals. Hold to the person's choices.

4.16 Liaison with the mental health team (stepped care)

• Purpose / when: Home Focus complements West Cork Mental Health Services. A community mental health nurse is on the team, local CMHNs are part of the support network, and the model is presented as stepped care [source: NLN brief 2021; Southern Star 2020]. The service aims to reduce admissions and readmissions [source: Southern Star 2021].
• Steps [synthesis]: (1) Agree with the person at the start what will be shared with their team, and when. (2) Flag early signs of relapse or rising risk to the person first, then (with consent, or without it only where safety law requires) to the clinical team. (3) Use the team nurse for clinical questions, so non-clinical staff stay non-clinical. (4) Feed back to the referrer at review and ending.
• Example language (illustrative): "You've said sleep's gone again and the voices are louder. Would you like me to let Catherine at the clinic know, or would you rather ring her yourself?"
• Watch for: Becoming the clinic's monitoring arm, which damages trust. Be transparent about any information you share.

4.17 Digital access support

• Purpose / when: During Covid-19 lockdowns staff met a large digital divide: many clients lacked reliable Wi-Fi and access to online training [source: Southern Star 2020]. The response is not described.
• Steps [synthesis]: (1) Check device, connectivity and skills. (2) Help the person get affordable devices or data and set them up. (3) Practise video calls and online course platforms together. (4) Keep phone and text as fallbacks.
• Watch for: Assuming online options reach rural clients. Check connectivity first.

4.18 Future planning and ending

• Purpose / when: Enabling future planning is a stated aim, and support is time-limited to 3–18 months [source: NLN brief 2021]. How endings are handled is not described [uncertain].
• Steps [synthesis]: (1) Name the time frame at the start and review it regularly. (2) About two to three months before the end, map which supports (community, education, employment, peer, clinical) will continue. (3) Taper visit frequency. (4) Hold a final review with the person: progress against their own goals, what helped, who to contact. (5) Send a summary to the referrer with consent, and explain how re-referral works.
• Example language (illustrative): "We've got about two months left. Let's look at what you've built and who'll be around for you after."
• Watch for: Abrupt endings or open-ended drift. It is working when the person's week is held up by community links, not by the service.

4.19 Service-level practice: outcomes and lived-experience involvement

• Purpose / when: For clinicians running or adapting the service. The 2008 evaluation measured self-reported change in personal and social functioning, social engagement, independent living, mental health, and links with community groups [source: NLN brief 2021 summarising Having Choices]. WHO guidance calls for people with lived experience in development, delivery and monitoring [source: NLN brief 2021].
• Steps [synthesis]: (1) Track each person's progress on their own goals plus the published domains at start, review and end. (2) Gather service-user feedback routinely. (3) Involve service users in service reviews and planning. (4) Track admissions and readmissions where data-sharing allows.

5. Handling problems

The published sources do not discuss problem handling. Apart from the quoted principles they draw on, all guidance in this section is the writer's own [synthesis], built from the service's published principles (non-coercion, do not direct, with not for, reliability, time, flexibility, peer support, stepped care).

5.1 Person does not engage (not home, does not answer, cancels)

• Never pursue in a way that feels like surveillance. Engagement is voluntary.
• Vary the format: text instead of call, a café instead of home, a peer worker instead of a professional.
• Keep your own appointments regardless. Reliability is often what earns later engagement (cf. the service user who valued staff being "good to their word") [source: NLN brief 2021].
• After a run of missed contacts, send a warm, no-pressure note saying the door stays open, and agree with the referrer when to close. Tell the clinical team at once if non-contact is a safety concern (5.6).
• Illustrative: "No pressure at all. I'll text Thursday to see if a chat suits. If not, that's grand."

5.2 Stuck: goals stall or the person "doesn't want anything"

• Go back to listening (4.4). Ask what a slightly better week would look like.
• Shrink the step until it is almost certain to succeed (one phone call, one walk to the shop).
• Check for hidden barriers: money, transport, benefits fear, family pressure, sedation or side effects (send these to the clinical team), stigma in a small community.
• Accept periods of just visiting. Time is a named principle [source: rehab.ie]. Then review together whether the service still fits within the 18-month frame.

5.3 Overwhelm during outings or tasks

• Agree an exit signal beforehand (4.9). Leave without fuss when it is used, and debrief kindly.
• Step back to an easier version and rebuild gradually. Never push past what was agreed.
• If overwhelm reflects acute deterioration (panic most days, psychotic symptoms, severe low mood), raise it with the person and the team nurse or referrer.

5.4 "Resistance" and disagreement with the worker

• Treat it as information about the person's goals, not a deficit. The service's stance is to not direct [source: Southern Star 2020].
• Name the disagreement and hand the decision back to the person.
• Illustrative: "It sounds like the course was more my idea than yours. What would you rather put the time into?"

5.5 Ruptures (missed visit by staff, broken confidence, feeling judged)

• Own your part quickly and plainly, apologise, and repair in person.
• If information was shared with the clinical team, explain exactly what and why.
• Offer a change of worker if the person wants it. A small team should plan cover for this.

5.6 Risk, crisis and suicidality

• Home Focus works 9–5 on weekdays and is non-clinical [source: NLN brief 2021; Southern Star 2020]. Every person needs a known out-of-hours crisis route.
• Workers should be trained to ask directly about suicidal thoughts, to stay with the person, and to link immediately with the mental health team, GP or emergency services under the local risk protocol. A crisis or safety plan belongs to the person and their clinical team, and Home Focus can help the person keep it to hand.
• Lethal-means safety: if risk is raised, support the person and family to store or remove medicines and other means safely, and pass concerns to the clinical team.
• Being transparent about any breach of confidentiality needed for safety protects the relationship.

5.7 Dependence on the worker

• Fading is built into every intervention (4.6–4.12). Name the time limit early (4.18).
• Watch for the person only going out with staff. Plan steps where they go alone with a text check-in.

5.8 Family conflict or family pressure

• Hold to the person's goals and consent rules (4.15). Offer the family separate information and carers' supports. Do not mediate family disputes beyond your role.

5.9 Pressure to act coercively (from referrers, family or the system)

• Requests to "make sure they take their medication" or to report everything conflict with the non-coercive, rights-based model [source for principle: NLN brief 2021; rehab.ie].
• Agree roles with the referrer at referral (4.1). Medication monitoring stays with the clinical team, and Home Focus staff explain their role openly to the person.

5.10 Rural and small-community difficulties

• Stigma and visibility: keep the low-profile presence the service credits for its success [source: Southern Star 2021]. Use unmarked cars, neutral venues, and agree with the person what to say if neighbours ask.
• Dual relationships: staff may know clients socially. Declare it and arrange cover where needed.
• Transport and digital gaps: plan travel together, combine trips, and check connectivity before relying on online courses (4.17) [source for digital gap: Southern Star 2020].
• Lone working in remote homes: follow the employer's lone-worker policy, with a check-in system and visit logs.

5.11 Ending too early or support running past 18 months

• Too early: review whether goals are met and whether supports are in place. Offer a planned re-referral route.
• Running over: return to future planning (4.18), and agree with the person and referrer what other services can take over.

5.12 Adapting the model elsewhere

• Keep the published core: voluntary referral through the mental health service, a mixed team with peer roles built in, home and community contact, practical accompaniment, links to training and employment, a time limit with future planning, and evaluation on the person's own goals [source: NLN brief 2021].
• No licence, certification or fidelity scale is published for Home Focus [uncertain]. The WHO technical package (section 2.3) is the fullest published description and should be read before replicating the model.

Sources

Sources used:

• West Cork Home Focus mental health service brief (NLN / Rehab Group, 2021)
• WHO recognition of NLN's Home Focus mental health programme (rehab.ie)
• Having Choices: An Evaluation of the Home Focus Project in West Cork (HSE publication page)
• Local mental health service praised by the World Health Organisation (Southern Star, 2020)
• Bantry mental health programme is one of world's top 25, says WHO (Southern Star, 2021)
• Community outreach mental health services: Promoting person-centred and rights-based approaches (WHO, 2021; publication page)
• Fresh take on mental healthcare (Irish Times, 2012; West Cork Mental Health Services context, no Home Focus content)

Cited by title; content not used here [uncertain]:

• World Health Organization (2021). Community outreach mental health services: promoting person-centred and rights-based approaches, section 2.3 "Home Focus, West Cork, Ireland". Geneva: WHO. ISBN 978-92-4-002580-6. CC BY-NC-SA 3.0 IGO.
• World Health Organization (2021). Guidance on community mental health services: promoting person-centred and rights-based approaches. Geneva: WHO.
• University College Cork / Home Focus partners (2008). Having Choices: An Evaluation of the Home Focus Project in West Cork. Published via HSE.
• Department of Health (2020). Sharing the Vision: A Mental Health Policy for Everyone. Dublin.