Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

In this guideline, 'complex psychosis' refers to a primary diagnosis of a psychotic illness (this includes schizophrenia, bipolar affective disorder, psychotic depression, delusional disorders and schizoaffective disorder) with severe and treatment-resistant symptoms of psychosis and functional impairment.

People with complex psychosis usually also have 1 or more of the following:

  • cognitive impairments associated with their psychosis

  • coexisting mental health conditions (including substance misuse)

  • pre-existing neurodevelopmental disorders, such as autism spectrum disorder or attention deficit hyperactivity disorder

  • physical health problems, such as diabetes, cardiovascular disease or pulmonary conditions.

Together, these complex problems severely affect the person's social and everyday functioning, and mean they need a period of rehabilitation to enable their recovery and ensure they achieve their optimum level of independence.

The guideline does not cover people who have a primary diagnosis of a non-psychotic illness. However, rehabilitation practitioners can also provide advice to services outside the rehabilitation pathway on appropriate treatment and support, including specialist placements and tailored support packages, for people with other primary mental health diagnoses or neurodevelopmental conditions, such as personality disorders or autism spectrum disorder.

1.1 Who should be offered rehabilitation?

1.1.1 Offer rehabilitation to people with complex psychosis:

  • as soon as it is identified that they have treatment-resistant symptoms of psychosis and impairments affecting their social and everyday functioning

  • wherever they are living, including in inpatient or community settings.

    In particular, this should include people who:

  • have experienced recurrent admissions or extended stays in acute inpatient or psychiatric units, either locally or out of area

  • live in 24‑hour staffed accommodation whose placement is breaking down.

1.2 Overarching principles of rehabilitation

1.2.1 Rehabilitation services for people with complex psychosis should:

  • be embedded in a local comprehensive mental healthcare service

  • provide a recovery-orientated approach that has a shared ethos and agreed goals, a sense of hope and optimism, and aims to reduce stigma

  • deliver individualised, person-centred care through collaboration and shared decision making with service users and their carers involved

  • be offered in the least restrictive environment and aim to help people progress from more intensive support to greater independence through the rehabilitation pathway

  • recognise that not everyone returns to the same level of independence they had before their illness and may require supported accommodation (such as residential care, supported housing or floating outreach) in the long term.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on overarching principles of rehabilitation.

Full details of the evidence and the committee's discussion are in evidence review J: rehabilitation approaches, care, support and treatment.

1.3 Organising the rehabilitation pathway

1.3.1 All local mental healthcare systems should include a defined rehabilitation pathway as part of their comprehensive service.

1.3.2 Use the local joint strategic needs assessment to inform the commissioning of specific service components (see recommendation 1.3.4) that make up the rehabilitation pathway, to match the needs of the local population.

1.3.3 Conduct a local rehabilitation service needs assessment. This should include the number of people with complex psychosis who:

  • are currently placed out of area for rehabilitation

  • have recurrent admissions or extended stays (for example, longer than 60 days) in acute inpatient units and psychiatric intensive care units, either locally or out of area

  • live in highly supported (24‑hour staffed) accommodation

  • are receiving care from forensic services but will need to continue their rehabilitation locally when risks or behaviours that challenge have been sufficiently addressed (for example, fire setting, physical or sexual aggression)

  • are receiving care from early intervention for psychosis services and developing problems that are likely to require mental health rehabilitation services now or in the near future

  • are physically frail and may need specialist support in their accommodation

  • are young adults moving from children and young people's mental health services to adult mental health services.

1.3.4 The rehabilitation pathway should include the following components, as informed by the needs assessment:

1.3.5 Health and social care commissioners should work together with health services, local authorities, housing providers and other partners (third sector and independent sector providers, service users and their families and carers) to ensure that rehabilitation is provided as locally as possible for all those identified in the local rehabilitation service needs assessment.

1.3.6 Consider jointly commissioning the most specialised services (including highly specialist rehabilitation units and longer-term high-dependency rehabilitation units) across areas to provide these services at a regional level for people with particularly complex needs.

1.3.7 Ensure that the rehabilitation pathway is designed to provide flexibility, smooth transitions and support over the longer term, that enables people to:

  • join and leave the rehabilitation pathway at different points

  • move between parts of the pathway that provide higher or lower levels of support according to their changing needs

  • spend different periods of time at different stages of the pathway according to need

  • have access to more than 1 period of rehabilitation to progress successfully in their recovery and be swiftly referred back to the pathway if their needs increase and they would benefit from further rehabilitation.

The lead commissioner

1.3.8 Health and social care commissioners should jointly designate a lead commissioner to oversee the commissioning of the specific services that make up the defined rehabilitation pathway for people with complex psychosis.

1.3.9 The lead commissioner should:

  • have in‑depth knowledge and experience of commissioning services for people with psychosis and other severe mental health conditions

  • have knowledge of local rehabilitation services and partnerships

  • be familiar with best practice in rehabilitation.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on organising the rehabilitation pathway and the lead commissioner.

Full details of the evidence and the committee's discussion are in evidence review A: identifying people who would benefit most and evidence review P: supported accommodation (recommendation 1.3.2 and 1.3.4); evidence review F: components of an effective rehabilitation pathway (recommendations 1.3.1, 1.3.3, 1.3.5, 1.3.6 and 1.3.7); and evidence review G: integrated rehabilitation care pathways involving multiple providers (recommendations 1.3.8 and 1.3.9).

Joint working

Integrated rehabilitation pathway

1.3.10 The lead commissioner should work together with service providers to deliver an integrated rehabilitation pathway, by ensuring that:

  • regular communication is supported between senior service managers and senior clinicians across providers of different services within the pathway

  • budgets and other resources are shared between local authorities and health services, so that local and regional rehabilitation services meet the local population's needs

  • funding mechanisms support collaboration between service providers and do not create unhelpful or perverse funding incentives that undermine people's progression through the rehabilitation pathway

  • clinical records and care plans are shared between providers

  • service level agreements are developed so that relevant services and agencies can work together in a timely and flexible way, including for transitions between services (see recommendation 1.3.7)

  • services within the pathway are staffed by appropriately skilled staff

  • the remit for each of the services making up the pathway (see recommendation 1.3.1) is clearly specified, including the population they cover.

Transitions

1.3.11 The lead commissioner and service providers should ensure that transitions in people's care between the rehabilitation service and other mental health teams or primary care are:

  • guided by criteria that are clearly defined in local policy

  • supported by a group of local rehabilitation practitioners, with whom clinicians can discuss potential referrals and re-referrals and receive advice on appropriate treatment and support

  • supported by close collaboration, including comprehensive handovers or an individually tailored period of co‑working between services

  • agreed with the person and their family or carers (as appropriate) and the clinicians involved in the person's care, at least 3 months before the transition (unless a referral is urgent).

1.3.12 The lead commissioner and service providers should ensure that people have opportunities to visit potential supported accommodation before moving in to help them make an informed choice about the service.

1.3.13 The lead commissioner should think about ways to improve the sharing of information and IT systems between health and social care staff, particularly in relation to people placed out of area.

1.3.14 For more information on managing transitions, see the NICE guideline on transition between inpatient mental health settings and community or care home settings.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on joint working.

Full details of the evidence and the committee's discussion are in evidence review G: integrated rehabilitation care pathways involving multiple providers (recommendation 1.3.10); evidence review Q: factors associated with successful transition (recommendations 1.3.11 and 1.3.12); evidence review B: barriers in accessing rehabilitation services (recommendation 1.3.13); and evidence review R: supporting transitions (recommendations 1.3.14).

Working with other healthcare providers

1.3.15 The lead commissioner should oversee the agreement of local protocols and service level agreements with primary and secondary physical healthcare providers, for people having inpatient or community rehabilitation. These protocols should:

  • promote access to national physical health screening programmes, health promotion, monitoring and interventions (see the section on physical healthcare)

  • ensure there is a system to monitor and report people's access to physical healthcare and outcomes that takes into account the increased physical health risks for specific subgroups, for example the higher prevalence of metabolic syndrome and diabetes in people from black, Asian and minority ethnic groups

  • ensure that any physical health conditions are assessed and treated (see the section on physical healthcare)

  • ensure practitioners in primary care, secondary physical care and rehabilitation services work collaboratively and flexibly, drawing together the necessary expertise and capacity to manage physical health conditions

  • ensure that the processes of the Mental Capacity Act (including Court of Protection decisions) do not delay care and treatment.

1.3.16 The lead commissioner should agree local protocols with specialist substance misuse services for people having inpatient or community rehabilitation who have substance misuse problems. These should:

  • define local arrangements and the content of care to ensure people can get support from local substance misuse services

  • include in‑reach arrangements for people in inpatient rehabilitation services

  • monitor and review access to substance misuse services and outcomes.

1.3.17 The lead commissioner should agree a local protocol with the community mental health service to enable clozapine to be started or restarted in the community. This protocol should:

  • be drawn up by, or in consultation with, the community mental health services pharmacist

  • include all relevant safety checks

  • include informing the person's GP.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on working with other healthcare providers.

Full details of the evidence and the committee's discussion are in evidence review C: prevalence of comorbidity (recommendation 1.3.15); evidence review O: substance misuse (recommendation 1.3.16); and evidence review H: adjustments to standard treatment (recommendation 1.3.17).

1.4 Improving access to rehabilitation

1.4.1 The lead commissioner and service providers should provide information about the local rehabilitation pathway and how it is accessed to health and social care practitioners, people who may benefit from rehabilitation and their families and carers.

1.4.2 The lead commissioner should work together with service providers to ensure that everyone with complex psychosis has access to rehabilitation services regardless of age, gender, ethnicity and other characteristics protected by the Equality Act 2010, and should actively monitor and report on access at least every 6 months.

1.4.3 If any differences are found in rates of access for specific groups of people (for example, women or ethnic groups) compared with anticipated rates, these should be addressed, for example through:

  • providing bespoke services for specific groups, such as women-only services

  • providing outreach into other services that work with under-served groups, or home visiting

  • providing tailored information and advocacy.

1.4.4 Service providers should support people to access legal advice about their immigration status if required.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on improving access to rehabilitation.

Full details of the evidence and the committee's discussion are in evidence review B: barriers in accessing rehabilitation services.

1.5 Delivering services within the rehabilitation pathway

Multidisciplinary teams

1.5.1 Inpatient and community rehabilitation services for people with complex psychosis should be staffed by multidisciplinary teams comprising a range of professionals with skills and competence in mental health rehabilitation, including:

  • rehabilitation psychiatrists

  • practitioner psychologists

  • nurses

  • occupational therapists

  • social workers

  • approved mental health professionals

  • support workers (including peer support workers)

  • specialist mental health pharmacists.

1.5.2 The multidisciplinary team should have access to physical exercise coaches, vocational trainers, welfare rights specialists, dietitians or nutritionists, podiatrists, speech and language therapists and physiotherapists.

Size of accommodation

1.5.3 Commissioners and providers of inpatient rehabilitation services and supported accommodation should be aware of the benefits to people of providing rehabilitation in smaller facilities, for example for promoting self-management, autonomy and social integration.

Service quality improvement

1.5.4 Consider using tools to support quality improvement such as the Quality Indicator for Rehabilitative Care (QuIRC) for inpatient rehabilitation units, and the QuIRC-Supported Accommodation (QuIRC‑SA) for supported accommodation.

1.5.5 Consider joining a peer accreditation or quality improvement forum.

Rehabilitation in the community

1.5.6 For people with complex psychosis who are living in supported accommodation, specialist clinical care should be provided by a multidisciplinary community mental health rehabilitation team whose work is integrated within an overall framework for the delivery of community mental health services. This team should:

  • coordinate the person's care and hold overall clinical responsibility for the person's mental health while they are living in the community

  • provide a designated care coordinator for each person but operate with a shared team caseload approach; this involves discussing people's care together at regular team meetings to pool and agree ideas about care and treatment

  • make the majority of contacts with the person in their home or community settings rather than where the team is based

  • work closely with staff at the person's supported accommodation to tailor people's care plans to their needs (see recommendation 1.7.7) and make clear which staff are responsible for providing different parts of the person's treatment and support as part of their rehabilitation

  • support and oversee the person's progression through the rehabilitation pathway by:

    • increasing the intensity of treatment and support during periods of relapse

    • providing ongoing contact and support during any periods of acute inpatient care

    • enabling the person's discharge home at the earliest opportunity

    • adjusting care plans to enable the person to gain the skills and confidence to manage in more independent accommodation

  • liaise with the person's GP about their physical healthcare

  • liaise with the relevant service when the person is ready to be discharged from the team to ensure a smooth transition.

1.5.7 Senior clinicians in the community mental health rehabilitation team should work with commissioners and supported accommodation providers to:

  • hold an overview of the local mental health supported accommodation services, including current vacancies and the quality of care provided

  • ensure that the rehabilitation pathway continues to develop in line with changes in the needs of the local population.

1.5.8 Community mental health rehabilitation teams should include as part of their team the staff who are designated care managers for people placed out of area.

Supported accommodation

1.5.9 To avoid unnecessary delays, staff should understand when and how to assess people's mental capacity in relation to decisions about moving to supported accommodation. Staff must follow the necessary steps set out in the Mental Capacity Act to enable this move. Also see the NICE guideline on decision making and mental capacity.

1.5.10 Supported accommodation services should:

  • provide support appropriate to the person's mental and physical health needs

  • promote stability and avoid unnecessary moves

  • be in a familiar place close to the person's social and cultural networks, if this is clinically appropriate

  • include support with tasks such as managing money and everyday living while encouraging independence and participation in society

  • give the person the option (if they are eligible) to have a personal budget or direct payment so they can choose and control their social care and support (for more information on personal budgets and direct payments, see the NICE guideline on people's experience in adult social care services)

  • give the person a safe place that feels like their own

  • recognise and safeguard individual vulnerability, risk, loneliness and exploitation.

Rehabilitation in inpatient settings

1.5.11 Inpatient rehabilitation services should have an expected maximum length of stay (which should be used as a guide rather than an absolute) to reduce the chance of people becoming 'institutionalised'.

1.5.12 Service providers should advise people about the impact of being in inpatient rehabilitation services for an extended period of time on their welfare benefits and the tenure of any existing housing tenancy.

Out-of-area placements

1.5.13 Out-of-area placements should be limited to people with particularly complex needs. This could include:

  • people with psychosis and brain injury, or psychosis and autism spectrum disorder, who need treatment in a highly specialist rehabilitation unit or

  • people who have a clear clinical or legal requirement to receive treatment outside their home area.

1.5.14 Out-of-area placements should only be provided after a local placement funding panel (including a rehabilitation practitioner, a senior service manager and local commissioner) has confirmed that the person's care cannot be provided locally.

1.5.15 A designated care manager (or 'out-of-area placement review officer') based within the community mental health rehabilitation team, should review the person's placement after the first 3 months and then every 6 months, to ensure it still meets their needs. This should include:

1.5.16 When people are placed in out-of-area rehabilitation services, provide an explanation in writing to the person (and their family or carers, as appropriate):

  • why they have been placed out of area

  • the steps that will be taken so they can return to their local area

  • how their family or carers will be helped to keep in contact

  • the advocacy support available to help them.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on delivering services within the rehabilitation pathway.

Full details of the evidence and the committee's discussion are in evidence review E: comparative effectiveness of different types of rehabilitation services (recommendations 1.5.1, 1.5.2, 1.5.6 to 1.5.8 and 1.5.13 to 1.5.16); evidence review F: components of an effective rehabilitation pathway (recommendations 1.5.3 to 1.5.5, 1.5.11); evidence review P: supported accommodation (recommendations 1.5.10 and 1.5.12); and evidence review R: supporting transitions (recommendation 1.5.9).

1.6 Recovery-orientated rehabilitation services

1.6.1 Staff in rehabilitation services should aim to foster people's autonomy, help them take an active part in treatment decisions and support self‑management.

1.6.2 Staff should build on people's strengths and encourage hope and optimism by:

  • helping people choose and work towards personal goals, based on their skills, aspirations and motivations

  • developing and maintaining continuity of individual therapeutic relationships wherever possible

  • helping them find meaningful occupations (including work, leisure or education) and build support networks using voluntary, health, social care and mainstream resources

  • helping people to gain skills to manage both their everyday activities and their mental health, including moving towards self-management of medication (see the recommendations on helping people to manage their own medicines)

  • providing opportunities for sharing experiences with peers

  • encouraging positive risk-taking

  • developing people's self-esteem and confidence

  • validating people's achievements and celebrating their progress

  • recognising that people vary in their experiences and progress at different rates

  • improving people's understanding of their experiences and the treatment and support that may help them – for example, through accessible written information, face-to-face discussions and group work.

Supporting people to make decisions

1.6.3 Ensure staff in rehabilitation services follow recommendations on communication needs in the section on co-production and enabling people to make decisions in NICE's guideline on people's experience in adult social care services.

1.6.4 Staff must meet people's communication needs as set out in the NHS Accessible Information Standard.

1.6.5 Ensure staff in rehabilitation services follow recommendations in the NICE guideline on decision making and mental capacity.

1.6.6 Provide support to people, if they need it, to express their views, preferences and aspirations about their care and support in line with recommendations in the NICE guideline on people's experience in adult social care services.

1.6.7 Local authorities must, in line with the Care Act 2014, provide independent advocacy to enable people to participate in:

  • care and support needs assessment and

  • care planning and

  • the implementation process and review

    where they would otherwise have substantial difficulty in doing so.

Universal staff competencies

These recommendations apply to all staff working in the services described in recommendation 1.3.4.

1.6.8 Ensure that staff training emphasises recovery principles so that all rehabilitation staff work with a recovery-orientated approach.

1.6.9 Staff should establish and maintain non-judgemental, collaborative relationships with people with complex psychosis.

1.6.10 Provide support for staff to acknowledge and manage any feelings of pessimism about people's potential for recovery. Support could include helping staff to share experiences and frustrations with each other, for example through supervision, reflective practice and peer support groups.

1.6.11 Ensure that staff attend appropriate diversity training and have the skills and competence to deliver non-discriminatory practice. They should understand that people may experience stigma resulting from their mental health condition, which could add to the stigma that people in a minority group (for example people from black, Asian and minority ethnic groups) may already experience.

1.6.12 Ensure that all staff are trained and skilled in supporting structured group activities and promoting daily living skills.

1.6.13 Ensure that staff have skills and competence in risk assessment and management to an appropriate level for the service they work in. For example, staff in high-dependency units should be able to work with people who have a history of, or currently present with, serious risks to themselves or others.

1.6.14 Rehabilitation services should ensure that their healthcare staff are competent to recognise and care for people with psychosis and coexisting substance misuse.

Maintaining and supporting social networks

1.6.15 Discuss with the person whether, and how, they want their family or carers to be involved in their care. Discuss this at regular intervals to take account of any changes in circumstances.

1.6.16 Ensure that staff receive training in the skills needed to negotiate and work with families and carers, and also in managing issues relating to information sharing and confidentiality.

1.6.17 Respect the rights and needs of carers alongside the person's right to confidentiality. Review the person's consent to share information with family members, carers and other services during their rehabilitation. Follow recommendations on involving families and carers in NICE's guideline on service user experience in adult mental health services.

1.6.18 Give families and carers information about support services in their area that can address their emotional, practical and other needs (this is particularly important if the person is accessing rehabilitation services for the first time).

1.6.19 For advice for adult carers about how to get a formal assessment of their own needs, follow recommendations in the NICE guideline on supporting adult carers.

1.6.20 Enable the person to maintain links with their home community by:

  • supporting them to maintain relationships with family and friends, for example, by finding ways to help with transport

  • helping them to stay in touch with social and recreational contacts

  • helping them to keep links with employment, education and their local community.

    This is particularly important if people are in an out-of-area placement.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on recovery-orientated rehabilitation services.

Full details of the evidence and the committee's discussion are in evidence review J: rehabilitation approaches, care, support and treatment (recommendations 1.6.1, 1.6.2 and 1.6.8); evidence review I: collaborative care planning (recommendations 1.6.3 to 1.6.7 and 1.6.15 to 1.6.20); evidence review B: barriers in accessing rehabilitation services (recommendations 1.6.9 to 1.6.11); evidence review K: activities of daily living (recommendation 1.6.12); evidence review A: identifying people who would benefit most (recommendation 1.6.13); and evidence review O: substance misuse (recommendation 1.6.14).

1.7 Person-centred care planning through assessment and formulation

Assessment

1.7.1 Offer people a comprehensive biopsychosocial needs assessment by a multidisciplinary team within 4 weeks of entering the rehabilitation service.

1.7.2 Include the following as part of the comprehensive assessment:

  • systematic assessment of primary and coexisting mental health problems

  • psychiatric history, including past admissions and treatments, responses to treatment, adverse effects from medicines, and medication adherence

  • medicines reconciliation by a specialist mental health pharmacist (see the section on medicines reconciliation in NICE's guideline on medicines optimisation)

  • vulnerabilities, including self-neglect, exploitation and abuse, and the person's risk of harm to themselves (including suicide) and others

  • physical health and wellbeing through a physical health check (see recommendation 1.7.3)

  • developmental history from birth, including milestones; relationships with peers; and problems at school (identifying any problems with social or cognitive functioning, motor development and skills or coexisting neurodevelopmental conditions)

  • occupational and educational history, including educational attainment and reason for leaving any employment

  • social history, including accommodation history (noting the highest level of independence); culture, ethnicity and spirituality; leisure activities; and finances

  • smoking, alcohol and illicit substance use

  • psychological and psychosocial history, including relationships, life history, experiences of abuse and trauma, coping strategies, strengths, resiliency, and previous psychological or psychosocial interventions

  • current social network, including any caring responsibilities

  • current skills in activities of daily living

  • current cognitive function, including any communication needs

  • the person's capacity to give informed consent for their treatment in line with the Mental Capacity Act 2005.

1.7.3 The initial physical health check in the comprehensive assessment by the rehabilitation service should include:

  • body mass index

  • waist circumference

  • full blood count

  • pulse and blood pressure

  • glycosylated haemoglobin (HbA1c), blood lipid profile, liver function tests, renal function tests and thyroid function

  • prolactin levels (for people on medicines that raise prolactin levels).

  • renal function tests and calcium levels (for people on lithium)

  • drug levels where appropriate, for example mood stabilising or anti-epileptic medicines, lithium and clozapine; do not offer valproate to women of childbearing potential, unless other options are unsuitable and the pregnancy prevention programme is in place (follow the Medicines and Healthcare Products Regulatory Agency [MHRA] safety advice on valproate use by women and girls)

  • electrocardiogram (ECG)

  • smoking, alcohol and illicit substance use

  • nutritional status, diet and level of physical activity

  • continence and constipation (particularly if the person is on clozapine)

  • any movement disorders

  • sexual health

  • vision, hearing and podiatry

  • oral inspection of general dental health

  • any difficulties with swallowing.

1.7.4 Be aware that people with complex psychosis are more likely to have multiple comorbidities, both mental and physical.

1.7.5 Be aware that people with complex psychosis have a higher prevalence of the following mental health conditions (which may contribute to complexity in rehabilitation):

1.7.6 Be aware that people with complex psychosis have a higher prevalence of the following physical health conditions (which may contribute to higher mortality in this population):

Care planning and review

1.7.7 Use the results of the comprehensive assessment to make a team formulation to inform treatment and care planning. The care plan should:

  • be developed collaboratively with the person

  • cover the areas of need identified during assessment (see recommendation 1.7.2), including both mental and physical health (for physical healthcare planning, see the section on responsibilities of different healthcare providers)

  • include the person's personal recovery goals

  • clarify actions and responsibilities for staff, the person themselves and their family or carers (where relevant).

1.7.8 Consider using accessible formatting to support the person in jointly developing their care plan, regardless of whether or not they have identified communication and information needs.

1.7.9 Review people's progress and care plans with them at multidisciplinary care review meetings at least:

  • every month in the inpatient rehabilitation service

  • every 6 months in the community.

1.7.10 Incorporate both staff-rated and service user-rated measurements of the person's progress into their care plan reviews, so that their support can be adjusted if needed.

1.7.11 Update care plans according to changes in the person's needs after these meetings and between meetings as needed. At every meeting or review, consider and plan with the person their transition to the next step in the rehabilitation pathway.

1.7.12 Ensure that care plans are shared with the person and everyone involved in the person's care (for example, clinicians, supported accommodation staff, and the person's family or carers, if the person agrees) at:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on person-centred care planning through assessment and formulation.

Full details of the evidence and the committee's discussion are in evidence review C: prevalence of comorbidity (recommendations 1.7.1 to 1.7.6) and evidence review I: collaborative care planning (recommendations 1.7.7 to 1.7.12).

1.8 Rehabilitation programmes and interventions

Daily living skills

1.8.1 Rehabilitation services should develop a culture that promotes activities to improve daily living skills as highly as other interventions (for example, medicines).

1.8.2 Provide activities to help people with complex psychosis develop and maintain daily living skills such as self-care, laundry, shopping, budgeting, using public transport, cooking and communicating (including using digital technology).

1.8.3 Support people to engage in activities to develop or improve their daily living skills by:

  • making a plan with each person that focuses on their needs and regularly reviews their goals

  • providing activities they enjoy and that motivate them

  • enabling them to practise their skills in risk-managed real life, such as kitchens and laundry rooms, wherever possible.

Interpersonal and social skills

1.8.4 Offer structured group activities (social, leisure or occupational) aimed at improving interpersonal skills. These could be peer-led or peer-supported and should be offered:

  • daily in inpatient rehabilitation services

  • at least weekly in community settings.

1.8.5 Offer regular opportunities to discuss the choice of group activities, for example by inviting everyone in the inpatient unit or supported accommodation service to a 'community meeting'.

1.8.6 Offer regular one-to-one sessions with a named member of staff to help the person plan and review their activity programme. The person could be:

  • the primary nurse in inpatient rehabilitation or

  • the person's care coordinator or keyworker in community rehabilitation services.

Engagement in community activities, including leisure, education and work

1.8.7 Programmes to engage people in community activities should:

  • be flexible and make reasonable adjustments to accommodate the person's illness and fluctuating needs

  • be individualised

  • develop structure and purpose in the person's day

  • aim to increase their sense of identity, belonging and social inclusion in the community

  • involve peer support

  • recognise people's skills and strengths.

1.8.8 Offer people the chance to be involved in a range of activities that they enjoy, tailored to their level of ability and wellness.

1.8.9 Offer people a range of educational and skill development opportunities, for example, recovery colleges and mainstream adult education settings, which build confidence and may lead to qualifications if the person wishes.

1.8.10 For people who would like to work towards mainstream employment, consider referring them to supported employment that uses the Individual Placement and Support approach.

1.8.11 Take into account and advise people about the impact of supported employment on their welfare benefits.

1.8.12 For people who are not ready to return to paid employment, consider alternatives such as transitional employment schemes and volunteering.

1.8.13 Consider providing a cognitive remediation intervention alongside vocational rehabilitation services.

1.8.14 Develop partnerships, for example with voluntary organisations and local employment advice schemes, to increase opportunities for support to prepare people for work or education.

Substance misuse

1.8.15 Ask people about their substance use (alcohol and illicit substances) when they enter the rehabilitation service.

1.8.16 Assess people's readiness to address their substance misuse, for example, through motivational interviewing.

1.8.18 Rehabilitation services should offer support and substance misuse interventions that aim to:

  • support harm reduction

  • change behaviour

  • help people develop coping strategies

  • improve engagement with substance misuse services

  • prevent relapse.

1.8.19 Substance misuse services should provide reasonable adjustments to help people use specialist substance misuse services, for example, by providing in‑reach services to people in the inpatient rehabilitation service.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation programmes and interventions.

Full details of the evidence and the committee's discussion are in evidence review K: activities of daily living (recommendations 1.8.1 to 1.8.3); evidence review L: interpersonal functioning (recommendations 1.8.4 to 1.8.6); evidence review M: engagement in community activities and evidence review J: rehabilitation approaches, care, support and treatment (recommendations 1.8.7 to 1.8.14); and evidence review O: substance misuse (recommendations 1.8.15 to 1.8.19).

1.9 Adjustments to mental health treatments in rehabilitation

1.9.1 For standard pharmacological and non-pharmacological treatments, follow recommendations in these sections of the NICE guideline on psychosis and schizophrenia in adults:

1.9.2 Discuss all mental health treatment options with people in line with recommendations on shared decision making in NICE's guideline on patient experience in adult NHS services.

1.9.3 Routinely monitor for and treat other coexisting mental health conditions, including depression, obsessive-compulsive disorder, anxiety, substance misuse, and risk of suicide (for guidance on these conditions, see NICE's web page on mental health and behavioural conditions).

1.9.4 For people diagnosed with a coexisting autism spectrum disorder, follow recommendations in the NICE guideline on autism spectrum disorder in adults.

1.9.5 Follow the recommendations on medicines-related communication systems when people move from one care setting to another in the NICE guideline on medicines optimisation.

Psychological therapies

1.9.6 Continue to offer people with complex psychosis individual cognitive behavioural therapy (CBT) and family intervention as recommended by the NICE guideline on psychosis and schizophrenia in adults. Follow the recommendations on delivery and monitoring in the section of that guideline on psychological interventions.

1.9.7 Consider additional psychological interventions, especially for people who are not ready to engage in CBT. Use psychological assessment and formulation to identify the most appropriate therapeutic intervention, guided by the person's preferences. Interventions could include:

  • those focusing on learned behaviours and how context influences behaviour

  • mindfulness approaches where people can be supported to focus on and attend to present experiences

  • approaches that include a focus on wider systems such as families or ward environments and their impact on the person.

1.9.8 Consider training all rehabilitation staff in psychologically informed approaches such as motivational interviewing, positive behaviour support, behavioural activation, trauma-informed care, and simple techniques for supporting people who are having troubling thoughts and feelings.

Pharmacological treatments

1.9.9 For people with complex psychosis whose symptoms have not responded adequately to an optimised dose of clozapine alone, consider augmenting clozapine with the following, depending on target symptoms:

  • an antipsychotic, for example aripiprazole for schizophrenia and related psychoses and/or

  • a mood stabiliser for psychosis with significant affective symptoms and/or

  • an antidepressant if there are significant depressive symptoms in addition to the psychotic condition.

    Be aware of potential drug interactions and note that not all combinations of treatments may be in accordance with UK marketing authorisations. Any off-licence prescribing should be communicated in writing with the person's GP. Seek specialist advice if needed, for example from another psychiatrist specialising in treatment-resistant symptoms or a specialist mental health pharmacist.

    Do not offer valproate to women of childbearing potential, unless other options are unsuitable and the pregnancy prevention programme is in place. Follow the MHRA safety advice on valproate use by women and girls.

1.9.10 Optimise the dosage (as tolerated) of medicines used to manage complex psychosis (see recommendations 1.9.1 and 1.9.9) according to the BNF and therapeutic plasma levels in the first instance.

1.9.11 Only use multiple medicines, or doses above BNF or summary of product characteristics limits, to treat complex psychosis:

  • if this is agreed and documented by the multidisciplinary team and the person (and their family, carer or advocate, as appropriate)

  • as a limited therapeutic trial, returning to conventional dosages or monotherapy after 3 months, unless the clinical benefits of higher doses or combined therapy clearly outweigh the risks

  • if the medicines are being used to treat specific symptoms that are disabling or distressing

  • after taking into account drug interactions and side effects, for example be cautious when adding an antidepressant to clozapine for someone who has experienced symptoms of mania

  • if systems and processes are in place for monitoring the person's response to treatment and side effects (monitoring may include physical examination, ECG and appropriate haematological tests).

1.9.12 Regularly review medicines used to manage complex psychosis and monitor effectiveness, adverse effects and drug interactions, including monitoring for constipation for those taking clozapine. Follow recommendations in the NICE guidelines on medicines optimisation and multimorbidity.

1.9.13 If pharmacological treatment is not effective, consider stopping the medicine:

  • following a thorough review of treatment

  • after agreeing and documenting the decision at a meeting with a multidisciplinary team and the person (and their family, carer or advocate, as appropriate)

  • with caution, particularly if the person has been on the medicine for many years

  • by reducing the dose slowly and closely monitoring the person for symptoms of relapse.

1.9.14 Monitor drug levels to check adherence and guide dosing:

1.9.15 Consider monitoring prolactin levels annually if the person is taking a medicine that raises prolactin, and more regularly if they have symptoms.

1.9.16 Monitor thyroid function, renal function and calcium levels at least every 6 months for people established on lithium, following recommendations on using lithium in the NICE guideline on bipolar disorder.

1.9.17 Consider annual ECGs for everyone with complex psychosis in rehabilitation services, and more regularly if they are taking medicines, combinations of medicines or medicines above BNF or summary of product characteristics limits that may alter cardiac rhythm (for example, causing prolonged QT interval).

1.9.18 Be aware that people may be using non-prescription substances (for example, alcohol, smoking or drugs) to cope with their symptoms, which may affect their prescribed medicines.

1.9.19 Consider referring for a second opinion from a relevant specialist when treating people whose symptoms have not responded well to standard treatment, and after following recommendations in the NICE guideline on medicines optimisation.

Adherence to medicines

1.9.20 Rehabilitation services should promote adherence to medicines in line with the NICE guideline on medicines adherence. Strategies to promote adherence could include avoiding complex medicine regimens and polypharmacy wherever possible.

Helping people to manage their own medicines

1.9.21 Offer people the opportunity to manage their own medicines through a graduated self-management of medicines programme if they have been assessed as able to take part. Follow recommendations on self-management plans in the NICE guideline on medicines optimisation.

1.9.22 Be flexible in tailoring the self-management of medicines programme and choice of equipment to the person's needs and preferences. This could include using monitored dosage systems together with a reminder system (for examples, charts or alarms).

Electroconvulsive therapy

1.9.23 See the NICE technology appraisal guidance on the use of electroconvulsive therapy.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on adjustments to mental health treatments in rehabilitation.

Full details of the evidence and the committee's discussion are in evidence review H: adjustments to standard treatment (recommendations 1.9.1 to 1.9.19) and evidence review K: activities of daily living (recommendations 1.9.20 to 1.9.22).

1.10 Physical healthcare

Responsibilities of different healthcare providers

1.10.1 GPs should develop and use practice case registers to monitor the physical and mental health of people with complex psychosis in primary care.

1.10.2 For people having community rehabilitation, GPs should assume lead responsibility for the person's physical health needs, including health checks and treatment of physical health conditions, working collaboratively with the community mental health rehabilitation team and other services as relevant.

1.10.3 For people having inpatient rehabilitation, the rehabilitation team should ensure that health checks, treatment of physical health conditions and other healthcare needs are addressed.

Coordinating physical healthcare

1.10.4 Nominate a professional from the rehabilitation service to provide continuity of physical healthcare across settings, liaising between the rehabilitation service, primary care, secondary mental health and secondary physical healthcare.

1.10.5 The nominated professional should work in collaboration with a healthcare professional to develop and oversee the physical healthcare plan, ensuring it is informed by the initial physical health check (see recommendation 1.7.3) and include:

  • health promotion interventions (see the section on healthy living, below)

  • routine screening through the national screening programmes (for example, cervical cancer) if the person is eligible

  • monitoring side effects of pharmacological treatments (see the section on pharmacological treatments)

  • monitoring of physical health (see the section on monitoring physical health, below)

  • monitoring of oral health

  • treatment plans for any risk factors or health conditions (see care and treatment for physical health conditions, below)

  • any reasonable adjustments needed for healthy living, screening, monitoring or treatments

  • the physical healthcare responsibilities for primary care, the rehabilitation service, other secondary mental health services and secondary physical healthcare.

1.10.6 Staff must follow the Mental Capacity Act 2005 when supporting people's physical health, including in primary and secondary physical healthcare screening, prevention, investigations and treatment.

Healthy living

1.10.7 Offer people who smoke help to stop smoking, even if previous attempts have been unsuccessful.

1.10.8 Be aware of the potential significant impact of reducing cigarette smoking on the metabolism of other drugs, particularly clozapine. Follow recommendations 1.1.3.4 and 1.1.3.5 in the physical health section of NICE's guideline on psychosis and schizophrenia in adults.

1.10.9 Offer people a combined healthy eating and physical activity programme and support them to take part in it.

1.10.10 Give people clear and accessible information about any health risks related to their:

  • medicines (side effects)

  • lifestyle, including:

    • diet and physical activity

    • smoking, alcohol or illicit substance use

    • oral hygiene

    • bone health

    • sexual and reproductive health.

1.10.11 Offer annual flu vaccination to people:

1.10.12 Explain to people that family members or carers who support them may also be eligible for free flu vaccination (see the section on flu vaccination in carers in NICE's guideline on flu vaccination).

1.10.13 Support people to maintain good oral hygiene and access dental appointments in line with NICE's guideline on oral health promotion.

1.10.14 Consider providing advice and support for good sleep hygiene and maximise opportunities for healthy sleep. For example, for inpatients, avoid barriers to sleep such as environmental factors or intrusive night-time checks.

Monitoring physical health

1.10.15 Offer people in rehabilitation services a routine physical health check at least annually. The annual physical health check should include:

  • body mass index

  • waist circumference

  • pulse and blood pressure

  • full blood count, HbA1c, blood lipid profile, renal function tests, liver function tests and thyroid function

  • smoking, alcohol or drug use

  • nutritional status, diet and level of physical activity

  • any movement disorders

  • sexual health

  • vision, hearing and podiatry

  • oral inspection of general dental health.

    For additional physical health checks associated with pharmacological treatments, see the section on pharmacological treatments.

1.10.16 Give people the choice, whenever possible, to have their annual physical health check at their GP practice or by a trained professional at the rehabilitation service (see recommendation 1.10.5).

1.10.17 Ensure a copy of the results of the physical health check is available to the rehabilitation service, primary care, secondary mental healthcare and secondary physical healthcare as appropriate, and is recorded in the case notes. Discuss any important findings with the person.

Care and treatment for physical health conditions

1.10.18 Use the annual physical health check in recommendation 1.10.15 to identify at the earliest opportunity people who:

1.10.19 Be alert to the possibility of infection with blood-borne diseases in people who could be at risk, for example because of homelessness, intravenous drug use or a history of sexually transmitted disease. For more information about those at risk and case identification, see the NICE guidelines on hepatitis B and C testing and HIV testing.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on physical healthcare.

Full details of the evidence and the committee's discussion are in evidence review C: prevalence of comorbidity (recommendations 1.10.1 to 1.10.3 and 1.10.19) and evidence review N: engagement in healthy living (recommendations 1.10.4 to 1.10.18).

Terms used in this guideline

Behavioural activation

A low-intensity intervention using goal setting and activity schedules to encourage people to engage in activities they have previously avoided due to factors such as low mood or motivation.

Cognitive remediation intervention

A manualised intervention to improve people's cognitive function.

Commissioners

At the time of publication, the development of integrated care systems, integrated care providers and NHS provider collaboratives is changing the commissioning landscape in the English health and care system. This may be formalised within new legislation. All references to 'commissioners' and 'commissioning' in this guideline should therefore be read in that context, wherever the commissioning function may sit and however it may operate in the future NHS in England.

Community mental health rehabilitation team

Teams providing specialist skills and care coordination to identify and address people's rehabilitation needs in the community. These teams can work in all community settings, but commonly work with people living in supported accommodation, often over many years, to enable their optimum level of functioning and independence.

Community rehabilitation units

Inpatient rehabilitation units that are set outside hospital grounds. These units provide the full complement of multidisciplinary treatment and support for people with ongoing complex needs that prevent them from being discharged from a high-dependency rehabilitation unit directly to supported accommodation. They build on the progress made in the high-dependency inpatient rehabilitation unit and have a strong focus on promoting independent living skills and community participation. Most referrals come from high-dependency rehabilitation units or acute inpatient units. Community rehabilitation units can only care for detained people under the Mental Health Act 1983 if the unit is registered as a ward. If they are not registered as a ward, they can care for people who are voluntary or those subject to a community order (for example, a community treatment order, guardianship, or conditionally discharged Section 37/41). The expected length of stay in a community rehabilitation unit is 1 to 2 years.

Complex psychosis

In this guideline, 'complex psychosis' refers to a primary diagnosis of a psychotic illness (this includes schizophrenia, bipolar affective disorder, psychotic depression, delusional disorders and schizoaffective disorder) with severe and treatment-resistant symptoms of psychosis and functional impairment.

People with complex psychosis usually also have 1 or more of the following:

  • cognitive impairments associated with their psychosis

  • coexisting mental health conditions (including substance misuse)

  • pre-existing neurodevelopmental disorders, such as autism spectrum disorder or attention deficit hyperactivity disorder

  • physical health problems, such as diabetes, cardiovascular disease or pulmonary conditions.

Together, these complex problems severely affect the person's social and everyday functioning, and mean they need a period of rehabilitation to enable their recovery and ensure they achieve their optimum level of independence.

Floating outreach

Services providing support to people living in time-unlimited, usually self-contained, individual tenancies. Staff are based off-site and visit for a few hours per week, providing practical and emotional support, with the aim of reducing support over time to zero.

Graduated self-management of medicines programme

Supporting a person to learn how to take and manage their own medicines. This usually involves them managing 1 day of medicines to begin with, with staff undertaking spot checks before progressing to managing 2 days, then 3 days and so on.

High-dependency rehabilitation units

Inpatient rehabilitation units for people with complex psychosis whose symptoms have not yet been stabilised and whose associated risks and challenging behaviours remain problematic. These units aim to maximise benefits of medication, address physical health comorbidities, reduce challenging behaviours, re‑engage families and facilitate access to the community. Most people in high-dependency units are detained under the Mental Health Act 1983. Most (80%) referrals to high-dependency units are from acute inpatient units and 20% from forensic units, with only occasional referrals of people living in the community. The expected length of stay is around 1 year.

Highly specialist rehabilitation units

Inpatient rehabilitation units for people with psychosis and comorbid conditions who need a specialist programme tailored to their specific comorbidity (such as acquired brain injury, severe personality disorder, autism spectrum disorder or Huntingdon's disease). Often, the complexity of the person's coexisting conditions is associated with greater support needs (more challenging behaviours and/or a greater risk to themselves and others) than people having treatment in a high-dependency rehabilitation unit. Referrals come from acute inpatient units or high-dependency rehabilitation units, and the expected length of stay is over 3 years.

Individual Placement and Support (IPS) approach

A method of supporting people with severe mental health problems into work. IPS finds people a job quickly and then provides time-unlimited individualised support to keep the job and manage their mental health.

Inpatient rehabilitation units

Units providing specialist inpatient care to people with complex psychosis. They can be based within a hospital or in the community.

Local placement funding panel

A panel not specific to rehabilitation, who agree funding (health, social care or both) for people to receive treatment within area or out of area, for example in a nursing or residential care home, or in an inpatient rehabilitation unit. The panel has a commissioner and senior service managers, as well as clinicians (a senior rehabilitation practitioner plus possibly a senior clinician who works in general adult care, not specifically rehabilitation).

Longer-term high-dependency rehabilitation units

These units provide longer-term inpatient rehabilitation for people with high levels of disability due to treatment-resistant symptoms and comorbid conditions that take more than 1 year to stabilise, and who have ongoing risks to others and/or challenging behaviours. The aims of longer-term high-dependency rehabilitation units are the same as for high-dependency rehabilitation units, and most referrals come from high-dependency rehabilitation units.

Motivational interviewing

A person-centred psychologically informed approach that supports behavioural change by helping people explore and resolve ambivalence towards change.

Out-of-area placements

A placement that provides treatment and support in an inpatient rehabilitation unit or supported accommodation outside the local area where a person usually lives, and/or outside the catchment area for the local authority that has responsibility for their housing. The placement may be away from the person's local area because there is no local service available, or because there are clinical or legal reasons that make local rehabilitation inappropriate for their needs, or because they prefer to have treatment outside their local area.

Positive behaviour support

A behaviour management system that seeks to understand the reasons behind problematic behaviours and to find alternative ways to meet goals and needs.

Psychologically informed approaches

Brief skills-based interventions that can be delivered by any staff member or service user who has had suitable training in the intervention. They include: guided self-help using online resources or workbooks; relaxation or mindfulness; stress workshops and behavioural activation groups.

Recovery colleges

Peer-led education and training programmes for mental health service users. They provide education as a route to recovery, not as a form of therapy. The courses are co‑devised and co‑delivered by people with lived experience of mental illness and by mental health professionals.

Recovery-orientated approach

There is no single definition of recovery for people with mental health problems, but the guiding principle is the belief that it is possible for someone to regain a meaningful life, despite serious mental illness. In this guideline, it refers to someone achieving the best quality of life they can, while living and coping with their symptoms. It is an ongoing process whereby the person is supported to build up their confidence and skills and resilience, through setting and achieving goals to minimise the impact of mental health problems on their everyday life.

Residential care

Communal facilities, staffed 24 hours, where day-to-day needs are provided (including meals, supervision of medicines and cleaning), and placements are not time limited. People do not hold a tenancy in a residential care home.

Supported accommodation

An umbrella term covering residential care, supported housing and floating outreach.

Supported housing

Shared or individual self-contained, time-limited tenancies with staff based on site up to 24 hours a day who help the person to gain skills to move on to less supported accommodation. The intended length of stay is usually about 2 years but in practice, only around one-third of people move on in that time.

Team formulation

A shared understanding of the issues that brought the person into rehabilitation services. It is their story, but draws on information from theory and research, as well as the experiences of the person, professionals and, where possible, others such as carers. It includes factors that made the person vulnerable to developing problems, factors that triggered the problems and factors that keep the problems going. A team formulation includes strengths and resources and points to ways that problems can be addressed.

Transitional employment schemes

These schemes give people a supported occupation in which to gain pre-vocational work experiences and potentially prepare for mainstream employment. One of the original examples was the 'clubhouse' model of psychosocial rehabilitation developed at Fountain House in New York.

Trauma-informed care

Care that is built on an understanding that anyone using services could have experienced psychosocial trauma and that this is likely to influence how they engage with care. Key principles include safety and avoiding re-traumatisation; relationship building; peer support; collaboration and mutuality; empowerment and choice; and an awareness of cultural, historical and gender issues.

Treatment-resistant symptoms

Persistent symptoms that have not responded to the range of treatments (including pharmacological treatments) recommended in the NICE guidance for the person's condition.

  • National Institute for Health and Care Excellence (NICE)