Community Discharge Pathways Project Alnwick villa 14 Northgate

Community Discharge Pathways Project: Alnwick villa 14, Northgate Hospital Michael Bell – Ward Manager July 2017

Session Aims • Background to the service and pathway • Description of the process • Outcomes

Villa 14 – Northgate Hospital • Secure hospital for offenders with learning disability (LD). • Male locked rehabilitation unit – 18 beds. • Detained under the Mental Health Act - MHA (1983). – Range of sections (3, 37/41) Patient Characteristics • Patients historically viewed as having refractory problems, difficult to place and ‘slow stream’ in rehabilitation terms. – Mild or borderline levels of intellectual functioning. – High levels of Emotionally Unstable (Dissocial and Impulsive) personality disorder characteristics. – Treatment resistant psychosis. – Autistic spectrum disorder characteristics are highly prevalent.

Clinical Model of Villa 14 • Since April 2011 non-medical responsible clinician (RC) Change in terms of clinical leadership, distributed responsibility and improved access to evidence-based psychological services. • From November 2011 Clinical Psychologist to support the role of the non-medical RC (alongside traditional role). – Whole multi-disciplinary team (MDT) approach to patient care (Nurses - qualified and unqualified, Occupational Therapy, Day Services, Psychology, Psychiatry, Speech and Language). – Discharge pathway developed using risk management principles within a formulation based approach. – Process driven through Pre-discharge Planning Meetings (PDPM)

Underpinning Formulation Model • 5 P’s (bio-psychosocial) model underpins the process – – – Predisposing (Background) Precipitation (Triggers) Perpetuating (What keeps it going? ) Protective (What helps? ) Plan • Based on the ‘what works’ principle. • With integration of other theoretical models as appropriate: – Attachment/Social learning/ criminological/ neuropsychological/ ‘Good lives’/ psychotic action, etc • Completed within the MDT to ensure it is collaborative.

The Pathway Discharge • A discharge pathway is a plan that shows you the steps needed to leave hospital and move into the right place in the community. • The house is split into blocks. Once all the blocks are completed you will be ready to leave hospital. Day Visits Over Night Stays Extended Leave Training and care plans In– reach work from new staff Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • These are the foundation activities which underpin the discharge process Day Visits Over Night Stays Extended Leave Training and care plans In– reach work from new staff Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • An individual service specification is written by the MDT describing the service required to manage the patients risks and meet their needs • . The service specification also describes how that service will meet section 117 requirements. Day Visits Over Night Stays Extended Leave Training and care plans In– reach work from new staff Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • The service needs these essential components. Day Visits Over Night Stays Extended Leave Training and care plans • Knowledgeable staff group In– reach work from new staff • An appropriate building • An appropriate peer group. Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • Engagement with LA and CCG commissioners is vital from the beginning of the discharge process. Day Visits Over Night Stays Extended Leave Training and care plans In– reach work from new staff • Commissioners have ownership of the service specification. Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • Patient engagement with the new team and forging of relationships is a crucial point in the discharge process. Over Night Stays Extended Leave Day Visits Training and care plans In– reach work from new staff • Achieving the best match with the service specification will help facilitate this. Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • In-reach work helps to build relationships and gives the receiving teams insight into the patients day to day activities and preferences. Day Visits Over Night Stays Extended Leave Training and care plans In-reach work from new staff team Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • Workshops aims are sharing knowledge, informing re risk, and discussing current management Day Visits Over Night Stays Extended Leave Training and care plans In– reach work from new staff • Joint Care planning by members of the MDT and receiving team to manage risk and meet care needs. Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • Appropriate levels of leave will be a requirement prior to the granting of discharge in restricted patients. Day Visits Over Night Leave Extended Leave Training and care plans In– reach work from new staff • Where leave is problematic discussions with relevant parties need to occur from the beginning of the process. Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

The Pathway Discharge • Within our service this is almost always via either CTO for unrestricted patients or Conditional discharge for restricted patients. Day Visits Over Night Stays Extended Leave Training and care plans In– reach work from new staff Patient visits the Service Health Funding Staff Team Local Authority Funding Property People to live with Service specification Care Plans Quality Time Treatment Day services

Outcomes for Patients • Four years pre and post implementation service review of the House model and discharge process. – – – Pre 12 discharges to post 37 discharges Pre 7 revocations (58%) to post 3 revocations (11%). Mean length of stay pre 3 years and 3 months to post 1 year and 2 months Uses of PRN medication (Lorazepam, Haloperidol) pre 260 to post 160 Uses of physical restraint pre 77 to post 44 Post implementation an average of 1 discharge every 5. 25 weeks

Outcomes for Patients • Over the total time of implementation (6 and a half years). • In total 47 have been discharged from hospital: – – 4 re-admissions to villa 14 due to placement breakdown. 3 have been discharged to alternative services. 1 is currently on a discharge pathway 1 discharge every 7 weeks

Summary • Pathway provided the MDT with a structure for discharging patients. • Promoted a flat MDT structure. • Enables: – successful discharge of patients who may have had a significant length of time (some over 20 years) in hospital. – Effective in working with patients who have complex risks and needs and progress to discharge. – Promotes positive working with community teams, agencies and providers.

Any Questions or Comments? Contact: Email; michael. bell@ntw. nhs. uk