This section highlights 3 areas of the transition between inpatient mental health settings and community and care home settings guideline that could have a big impact on practice and be challenging to implement, along with the reasons why change needs to happen in these areas. We identified these with the help of stakeholders and guideline committee members. For more information, see developing NICE guidelines: the manual. The manual also gives information on resources to help with implementation.
All practitioners have a role to play in ensuring care and support is provided in a therapeutic environment that is responsive to people's individual needs and choices while being focused on recovery. Creating the right culture needs skilled practitioners who work with people as active partners and have a good understanding of what makes a successful transition. People will benefit because they will experience care and support that is tailored to their needs and supports their recovery.
Transitions for people using acute mental health services can be complex. They often involve more than 1 agency and setting. Workload pressures in hospitals and community settings can lead to competing demands. A poor transition that is not person-centred can be stressful for people using mental health services and their families and carers. This can result in an unsatisfactory experience for all concerned and may impede recovery.
Embed principles of person-centred and recovery-focused care in all training, supervision and continuing professional development for practitioners involved in transitions. Publications from the Improving recovery through organisational change programme may be helpful; in particular those on supporting recovery in mental health services: quality and outcomes, making recovery a reality in forensic settings, peer support workers: a practical guide to implementation and recovery: a carer's perspective.
Ensure that mental health and social care practitioners inexperienced in working with people from diverse backgrounds are able to seek advice, training and supervision from colleagues who do have this experience (in line with the section on community care in the NICE guideline on service user experience in adult mental health).
Ensure that health and social care practitioners have opportunities to learn about the emotional and practical impact of transitions, change and loss. This should include discussion of the particular risks and challenges of transitions.
Offer training opportunities to all professionals involved in assessments for admission under the Mental Health Act 2007. This includes police, community psychiatric nurses, approved mental health professionals, psychiatrists, GPs, ambulance staff, general hospital staff and psychiatric liaison staff. Training opportunities may include:
training delivered by people who use services
training done alongside other involved professionals.
The challenge: Ensuring effective communication between teams, and with people using services and their families and carers
Good communication is important – both between health and social care practitioners working in multidisciplinary teams and between practitioners and people using mental health services (and their families, parents or carers). Good communication leads to better coordinated care and a better experience for the person.
Practitioners need to work together, across physical and professional boundaries, to ensure that people experience good transition. People need help to stay in touch with their life outside the hospital, including relationships, employment, education and their local community. But this can be particularly hard if they live some distance from the hospital, or if a number of agencies are involved.
Co-producing care plans with people helps them to feel more in control and be active partners in their own care and recovery. Care plans should draw on all forms of documented treatment intentions and preferences relating to the person (including crisis plans, discharge and recovery plans, and Care Programme Approach documentation). Lack of coordination between plans can result in frustration and stress if people are asked for information repeatedly. Plans should be reviewed regularly. Planning early for each stage of admission and discharge can ensure better continuity of care and a better experience for the person as they move between services.
Requiring practitioners to explain to people and their carers why a restriction (involuntary admission, observation or community treatment order) has been applied is likely to lead to improved communication with people and their carers. It will also support more reflective practice.
Identifying the person's family or carers early on means they can be more involved in the person's care and support from an earlier stage. It can also aid practitioners' understanding of the person and their needs.
Building in the flexibility to pace a transition according to a person's cognitive and communication needs may mean that changes are needed to the way things are usually done.