Improved Transitions and Discharge Task and Finish Group Phil Coombes & Amy Spencer Clinical Director Elysium Healthcare & Ward Manager Lincolnshire Partnership

Why are we looking at transitions?

Aims of Group Ensuring smoother transitions between inpatient services and community Reducing unnecessary delays in the person’s stay Improving discharge arrangements Keep the service user key to the journey of discharge Clearer goals / routes to discharge

Key Tasks and Progress so far Ending the need to carry out an access assessment at every potential change in level of security- what process will be put in place to avoid the need for this? Discussions between the group of identifying the full pathway at admission using home area and service user need / requests to propose initial pathway needed a more joined up team Developing a “decision tree” to support transition Reviewing the tree developed by admissions group and to adapt to fit levels of security, all levels of security leads identified to complete a basic expectation to move to next level to be shared with service users from the start to know what is needed next to achieve a move

Oversight of prison model pilot development CFS working more assertively with people in inpatients and support transition into the community (assertive transitions team) Update from submitted bid and close working with this task and finish, as with admission task and finish group to ensure smoother ways in and out of forensic services, and integration with units locally Oversight of prison model pilot development We now have representative from offender health attending and they are looking at current ways of referral in to services at correct levels using decision tree and guidance being developed, to help ensure appropriate and timely placement

Key tasks and progress so far “Blending” levels of security eg oversight of the Women’s Pilot in this group Awaiting feedback from start of the pilot to see what can be learnt, can this be done at other levels i.e low and step down (funding crossover) More assertive/ proactive discharge processes and pathways: Single Point of Exit? The use of the Hub discussed at the other task and finish groups to allow full overview through services and out incorporating the assertive in reach team trigger points for key people to attend from receiving services sign up by teams for attendance at 6 month pre discharge point (with RC’s attendance from the community at final step out?)

How it feels at the moment

Roles of the Hub for transitions Really need to get this part right ! Oversight of beds across all geographical areas Nearly there Awareness of all units location and specialities (now submitted and in place) Central component to ensure all parties are aware and triggered at right time via CPA process to allow for more joined up step down Work to be done and agreement of who Can we move case managers straight over as they have existing knowledge ?

What will we use to know its working ? Better experience for the service user and family; ensuring choice, locality and involvement are fundamental principles Reduction in duplication (right people right place right time) Reduction in LOS More transparent processes Better support in terms of transition into the community and relapse prevention A more responsive and joined up forensic MH system

Where are we now?

Where are we now? Key clinicians identified at all levels of security identified and attending Links to admissions and community forensic teams task and finish groups to ensure liked up process Existing standards / process received from NHSE as a starting point re Levels / standards of security identified (not re-inventing the wheel) Use existing good practice to help produce the most integrated way forward (Lincolnshire process meeting discussed with CCG attendance to assist in all steps)

Group work tasks (what we need help with/ what have we missed?) 1. What makes a good transition? Consider this in terms of both up and down levels of security

Group work tasks (what we need help with/ what have we missed?) 2. How can we use the Care Programme Approach (CPA) process more effectively to facilitate transition? Consider this in terms of what works well and areas that could be improved

Group work tasks (what we need help with/ what have we missed?) 3. Should IMPACT look at developing a Personal Passport to support transition? Consider how can it facilitate transition and what should it contain?