Implementation: getting started

Implementation: getting started

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.

Challenges for implementation

The challenge: Delivering services that are person-centred and focus on recovery

See recommendations 1.1.1 to 1.1.4 and 1.5.1.

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.

What can commissioners, managers and practitioners do to help?

The challenge: Ensuring effective communication between teams, and with people using services and their families and carers

See recommendations 1.1.5 and 1.1.8, 1.2.8, 1.3.10 to 1.3.14 and 1.4.1 to 1.4.8.

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.

What can commissioners and managers do to help?
  • Ensure that effective systems are in place to help practitioners communicate effectively.

What can health and social care practitioners do to help?
  • Ensure that information about people is shared with colleagues if appropriate (in line with information-sharing protocols).

  • If people are placed outside the area in which they live, ensure that good communications are maintained, both between practitioners in different services and between practitioners and people using services (and their families and carers).

  • Ensure that there is good communication between service providers and people using mental health services (and, if appropriate, their families and carers).

  • Offer information on treatment and services to people at the point they need it.

  • Think carefully about what information people need and how to make sure they have understood it. This could be checked during a conversation with the person when they are feeling less unwell.

The challenge: Co-producing comprehensive care plans that meet people's changing needs

See recommendations 1.1.2 and 1.1.4, 1.2.2 to 1.2.3, 1.3.15 and 1.6.10 to 1.6.11.

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.

What can commissioners and managers do to help?
  • Ensure that health and social care practitioners involved in transitions to and from mental health hospitals have the skills to:

    • carry out needs assessments

    • develop care and discharge plans in collaboration with the person.

What can health and social care practitioners do to help?
  • Ensure that all planning is person-centred and involves the person as an active partner in their care.

  • Start all plans at the earliest possible opportunity.

  • Focus planning on enabling people to have a seamless transition into and out of hospital.

  • Recognise that care plans are 'living documents' that should be regularly reviewed and take account of changed circumstances.