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Assertive Outreach Rehabilitation Team (AORT)

How our service can help you

The Assertive Outreach Rehabilitation Team (AORT) offers a model that utilises a whole systems approach to rehabilitation from mental illness. The tripartite model consists of two rehabilitation branches and an assertive outreach branch, utilising a shared care approach across the team with the aims of recovery and move-on at the forefront. The Assertive Outreach (AO) branch aims to provide a more enhanced service for people diagnosed with serious mental illness and to deliver evidence-based interventions and care whilst increasing service user and carer satisfaction. AO adopts an assertive and proactive way of working, utilising a whole-team approach to provide continuity of care and encourage creativity in engagement and positive risk taking. The AO multidisciplinary team provides most interventions from within the team and delivers care wherever is required and most appropriate. The rehabilitation branches aim to provide an enhanced service for service users with diagnosed serious mental health conditions that require supported or residential accommodation, embodying evidence based practice to promote rehabilitation, social inclusion and increased independence. The rehabilitation branches aim to use the FACT approach to team work, operating shared care across a proportion of the team caseload. The whole team approach embodies independence and recovery from treatment resistant mental ill health.

  • Contact the service

    Site Location: Marina house Email: AO Team Leader: R1 Team Leader: R2 Team Leader: Phone Number: 0203 228 9454
  • Disabled Access: There is disability access to the ground floor of each building.
  • Address: Marina House 1st Floor 63-65 Denmark Hill,
    SE5 8RS
  • Other essential information

  • Conditions: Southwark, Schizophrenia, schizo-affective disorder, psychotic illness, complex needs, Community Mental Health.

Eligibility criteria


All persons accepted into the Service will be normally resident in the London Borough of Southwark.

 Referrals will be for persons of 18 years and above and will be known to or using Mental Health Services at the time of referral.

  • Persons referred will have a severe and enduring mental disorder such as schizophrenia, schizo-affective disorder and other psychotic illnesses, associated with a high level of disability.
  • Persons referred will have a history of high use of hospital inpatient (more than two admissions or more than a total of 6 months inpatient care in the past two years) or intensive home based care.
  • Mainstream services will have difficulty in maintaining lasting and consenting contact with clients.
  • In addition to the above the clients will have multiple complex needs including at least one or more of the following:
    • Detained under Mental Health Act on at least one occasion in the past 2 years
    • Dual diagnosis of substance misuse and serious mental illness
    • Poor response to previous treatment
    • Unstable accommodation or homelessness
    • Problems adhering to medication
    • History of violence or persistent offending
    • Poor social functioning including unemployment
    • Significant risk of persistent self-harm or neglect
    • A diagnosis of Personality Disorder
  • All clients should / will be on CPA, and at risk of falling out of contact with the services.
  • Although there are no diagnostic exclusions, the service is not aimed at people whose primary problem is one of brain injury, drug or alcohol abuse, personality disorder or learning disabilities.
  • The team will work with both inpatients and clients living in the community.
  • Persons referred will usually have been previously supported by Mental Health Team for Homeless People (START), the Continuing Care Teams or the Early Intervention Team.


 REFERRAL CRITERIA, Rehab 1 and 2 branch:

  • The two AORT rehab branches work with all Southwark based service users who live in certain Southwark mental health commissioned/funded supported or residential accommodation.
  • It is expected service users have lived there at least six weeks and are not at risk of eviction or imminent hospital admission.


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