Recommendations

Although most of the recommendations in this guideline cover both planned and unplanned admissions, some (like those on pre-admission planning) are only applicable to planned admissions. If an admission is unplanned, then these recommendations should be applied at the soonest possible point after admission, if appropriate to the person's individual circumstances.

People have the right to be involved in discussions and make informed decisions about their care, as described in 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 professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Overarching principles

1.1.1 Ensure the aim of care and support of people in transition is person-centred and focused on recovery.

1.1.2 Work with people as active partners in their own care and transition planning. For more information, see the section on relationships and communication in NICE's guideline on service user experience in adult mental health services.

1.1.3 Support people in transition in the least restrictive setting available (in line with the Mental Health Act Code of Practice).

1.1.4 Record the needs and wishes of the person at each stage of transition planning and review.

1.1.5 Identify the person's support networks. Work with the person to explore ways in which the people who support them can be involved throughout their admission and discharge.

1.1.6 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 admitted to mental health units outside the area in which they live.

1.1.7 Mental health services should work with primary care, local authorities and third sector organisations to ensure that people with mental health problems in transition have equal access to services. This should be based on need and irrespective of:

  • gender

  • sexual orientation

  • socioeconomic status

  • age

  • disability

  • cultural, ethnic and religious background

  • whether or not they are receiving support through the Care Programme Approach

  • whether or not they are subject to mental health legislation.

1.1.8 Give people in transition comprehensive information about treatments and services for their mental health problems at the time they need it. If required, provide information:

1.2 Before hospital admission

Planning and assessment

1.2.1 Mental health practitioners supporting transition should respond quickly to requests for assessment of mental health from:

  • people with mental health problems

  • family members

  • carers

  • primary care practitioners (including GPs)

  • specialist community teams (for example, learning disability teams)

  • staff such as hostel, housing and community support workers.

    Assessments for people in crisis should be prioritised.

1.2.2 If admission is being planned for a treatment episode involve:

  • the person who is being admitted

  • their family members, parents or carers

  • community accommodation and support providers.

1.2.3 When planning treatment for people being admitted, take account of the expertise and knowledge of the person's family members, parents or carers.

1.2.4 Allow more time and expert input to support people with complex, multiple or specific support needs to make transitions to and from services, if necessary. This may include:

  • children and young people

  • people with dementia, cognitive or sensory impairment

  • people on the autistic spectrum

  • people with learning disabilities and other additional needs

  • people placed outside the area in which they live.

1.2.5 For planned admissions, offer people an opportunity to visit the inpatient unit before they are admitted. This is particularly important for:

  • children and young people

  • people with dementia, cognitive or sensory impairment

  • people on the autistic spectrum

  • people with learning disabilities and other additional needs

  • people placed outside the area in which they live.

1.2.6 If it is not possible for the person to visit the inpatient unit that they will be admitted to in advance, consider using accessible online and printed information to support discussion about their admission.

1.2.7 During admission planning, record a full history or update that:

  • covers the person's cognitive, physical and mental health needs

  • includes details of their current medication

  • identifies the services involved in their care.

    For more information, see the section on medicines reconciliation in NICE's guideline on medicines optimisation.

1.2.8 If more than 1 team is involved in a person's transition to, within and from a service, ensure there is ongoing communication between the inpatient team and other relevant teams that include:

  • community health or social care providers, such as:

    • the community mental health team

    • the learning disability team

    • teams that work with older people

  • child and adolescent mental health services (CAMHS)

  • housing support teams

  • general hospital or psychiatric liaison teams.

Crisis plans

1.2.9 Support people who have had more than 1 admission to develop a crisis plan as part of their care planning process. This should include:

  • relapse indicators and plans

  • who to contact in a crisis

  • coping strategies

  • preferences for treatment and specific interventions

  • advance decisions.

    For more information, see the section on community care in NICE's guideline on service user experience in adult mental health services.

1.3 Hospital admission

General principles

1.3.1 Start building therapeutic relationships as early as possible to:

  • lessen the person's sense of being coerced

  • encourage the person to engage with treatment and recovery programmes and collaborative decision-making

  • create a safe, contained environment

  • reduce the risk of suicide, which is high during the first 7 days after admission.

    This is particularly important for people who have been admitted in crisis.

1.3.2 Practitioners involved in admission should refer to crisis plans and advance statements when arranging care.

1.3.3 Advance decisions must be followed in line with the Mental Capacity Act 2005.

1.3.4 At admission, offer all people access to advocacy services that take into account their:

  • language and communication needs

  • cultural and social needs

  • protected characteristics (see the GOV.UK page about discrimination).

1.3.5 Health and social care practitioners admitting someone with cognitive difficulties should try to ensure the person understands why they have been admitted.

1.3.6 During admission, discuss with the person:

  • any strategies for coping that they use

  • how they can continue to use, adapt and develop positive coping strategies on the ward.

1.3.7 Start discharge planning at admission or as early as possible when in crisis (for more information, see section 1.5).

1.3.8 For recommendations on assessing and treating people who have been detained under the Mental Health Act, see section 1.8 of NICE's guideline on service user experience in adult mental health services.

1.3.9 For recommendations on crisis, including crisis admissions, see section 1.5 in NICE's guideline on service user experience in adult mental health services.

Out-of-area admissions

1.3.10 If the person is being admitted outside the area in which they live, identify:

  • a named practitioner from the person's home area who has been supporting the person

  • a named practitioner from the ward they are being admitted to.

1.3.11 The named practitioners from the person's home area and the ward should work together to ensure that the person's current placement lasts no longer than required. This should include reviewing the person's care plan, current placement, recovery goals and discharge plan at least every 3 months, or more frequently according to the person's needs. This could be done in person or by audio or videoconference.

1.3.12 For people admitted to hospital outside the area in which they live, take into account the higher risk of suicide after discharge at all stages of the planning process (see the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness). This should include:

  • assessing the risk

  • discussing with the person how services can help them to stay safe

  • discussing with the person's family members, parents or carers how they can help the person to stay safe.

Legal status of person being admitted

1.3.13 The senior health professional responsible for the admission should tell the person being admitted about their legal status at the point of admission. They should:

  • use clear language

  • discuss rights and restrictions with the person

  • provide written and verbal information

  • make the discussion relevant to the ward the person is being admitted to

  • explain whether they are under observation and what this means (see observations and restrictions).

1.3.14 A senior health professional should ensure that discussions take place with the person being admitted to check that:

  • they have understood the information they were given at admission

  • they know they have a right to appeal, and that information and advocacy can be provided to support them to do so if they wish

  • they understand that any changes to their legal status and treatment plans will be discussed as they occur.

Observations and restrictions

1.3.15 The admitting nurse or person responsible should tell the person what level of observation they are under and:

  • explain what being under observation means

  • explain clearly the reasons why the person is under observation and when, or under what circumstances, this will be reviewed

  • explain how they will be observed and how often

  • explain how observation will support their recovery and treatment

  • discuss with the person how their preferences will be respected and how their rights to privacy and dignity will be protected

  • offer the person an opportunity to ask questions.

1.3.16 Ensure that restrictions, including restrictions on access to personal possessions:

  • are relevant and reasonable in relation to the person concerned

  • take into consideration the safety of the person and others on the ward

  • are explained clearly to ensure the person understands:

    • why the restrictions are in place

    • under what circumstances they would be changed.

Addressing personal concerns

1.3.17 To support the person's transition to the ward the admitting nurse or person responsible should make the following items available if the person needs them:

  • a toothbrush

  • hygiene products

  • nightwear.

    This is particularly important for people who have been admitted in crisis.

1.3.18 Give the person verbal and written information about ward facilities and routines (see the section on hospital care in NICE's guideline on service user experience in adult mental health).

1.3.19 At admission, a senior healthcare professional should discuss all medication and care needs with the person being admitted. This should include:

  • physical healthcare needs

  • pregnancy, breastfeeding or the need for emergency contraception

  • advice about immediate addiction issues, treatment and support

  • mental health treatment.

1.3.20 The admitting nurse or person responsible should discuss with the person how to manage domestic and caring arrangements and liaise with the appropriate agencies. This may include:

  • people they have a responsibility to care for, such as:

    • children

    • frail or ill relatives

  • domestic arrangements, in particular:

    • home security

    • tenancy

    • benefits

    • home care service

    • pets.

1.3.21 On admission, ensure people (particularly children and young people) know who they can talk to if they are frightened or need support. For more information, see the section on hospital care in NICE's guideline on service user experience in adult mental health services.

1.3.22 Identify whether the person has any additional need for support, for example, with daily living activities. Work with carers and community-based services, such as specialist services for people with learning or physical disabilities, to provide support and continuity while the person is in hospital.

1.4 Support for families, parents and carers throughout admission

1.4.1 Identify a named practitioner who will make sure that the person's family members, parents or carers receive support and timely information (see the section on sharing information with families, parents and carers).

1.4.2 Practitioners should start to build relationships with the person's family members, parents or carers during admission. This should be done:

  • in an empathetic, reassuring and non-judgemental way

  • acknowledging that admission to hospital can be particularly traumatic for families and carers, particularly if it is the person's first admission.

1.4.3 Arrange for parents to have protected time at an early point in the process of admitting their child to discuss the process with the relevant practitioners.

1.4.4 Try to accommodate parents' or carers' working patterns and other responsibilities so that they can attend meetings (if the person they care for wants this). This should include:

  • care planning meetings

  • discharge planning meetings

  • other meetings concerning the care of the person.

Sharing information with families, parents and carers

1.4.5 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 the inpatient stay. For more information, see the subsection on involving families and carers in NICE's guideline on service user experience in adult mental health services.

1.4.6 Throughout admission, give families, parents or carers clear, accessible information about:

  • the purpose of the admission

  • the person's condition (either general, or specific if the person agrees to this)

  • the treatment, care and support that the person is receiving

  • the inpatient unit, including:

    • the ward and the wider hospital environment

    • the practicalities of being in hospital

    • resources that are available, including accommodation for families

    • visiting arrangements

  • preparing for discharge.

1.4.7 Give families, parents and carers information about support services in their area that can address emotional, practical and other needs (this is particularly important if this is the person's first admission).

1.4.8 Give young carers (under 18) of people in transition relevant information that they are able to understand.

Carers' assessments

1.4.9 Practitioners involved in admission and discharge should always take account of carers' needs, especially if the carer is likely to be a vital part of the person's support after discharge.

1.4.10 Identify carers (including young carers) who have recognisable needs. If the carer wishes it, make a referral to the carer's local authority for a carer's assessment (in line with the Care Act 2014). Ensure a carer's assessment has been offered, or started, before the person is discharged from hospital.

1.5 Hospital discharge

1.5.1 Health and social care practitioners in the hospital and community should plan discharge with the person and their family, carers or advocate. They should ensure that it is collaborative, person-centred and suitably-paced, so the person does not feel their discharge is sudden or premature. For more information, see NICE's guideline on service user experience in adult mental health services.

Maintaining links with the community

1.5.2 Work with the person throughout their hospital stay to help them:

  • keep links with their life outside the hospital (see recommendation 1.1.6)

  • restart any activities before they are discharged.

    This is particularly important for people who need a long-term inpatient stay, are placed out-of-area, or who will have restricted access to the community.

1.5.3 Before discharge offer:

  • phased leave (the person can have trial periods out of hospital before discharge)

  • phased return to employment or education (the person can gradually build up hours spent in employment or education).

    This is particularly important for people who have been in hospital for an extended period and people who have had restricted access to the community.

1.5.4 Before discharging a person who is in education or training, arrange a planning meeting between them and a named person from the education setting to plan their return to learning.

Education – for people under 18

1.5.5 Children and young people under 18 must have continued access to education and learning throughout their hospital stay, in line with the Education Act 1996.

1.5.6 Before the child or young person goes back into community-based education or training:

  • identify a named worker from the education or training setting to be responsible for the transition

  • arrange a meeting between the named worker and the child or young person to plan their return.

Accommodation

1.5.7 Before discharging people with mental health needs, discuss their housing arrangements to ensure they are suitable for them and plan accommodation accordingly. This should take into account any specific accommodation and observation requirements associated with risk of suicide.

1.5.8 Give people with serious mental health issues who have recently been homeless, or are at risk of homelessness, intensive, structured support to find and keep accommodation. This should:

  • be started before discharge

  • continue after discharge for as long as the person needs support to stay in secure accommodation

  • focus on joint problem-solving, housing and mental health issues.

Helping the person to prepare for discharge

1.5.9 Before discharge, offer a series of individualised psychoeducation sessions for people with psychotic illnesses to promote learning and awareness. Sessions should:

  • start while the person is in hospital

  • continue after discharge so the person can test new approaches in the community

  • cover:

    • symptoms and their causes

    • what might cause the person to relapse, and how that can be prevented

    • psychological treatment

    • coping strategies to help the person if they become distressed

    • risk factors

    • how the person can be helped to look after themselves

  • be conducted by the same practitioner throughout if possible.

1.5.10 Consider psychoeducation sessions for all people with other diagnoses as part of planning discharge and avoiding readmission.

1.5.11 During discharge planning, consider group psychoeducation support for carers. This should include signposting to information on the specific condition of the person they care for.

1.5.12 Consider a staged, group-based psychological intervention for adults with bipolar disorder who have had at least 1 hospital admission and are being discharged from hospital. This should include:

  • evaluation by a psychiatrist within 2 weeks of discharge

  • 3 sequential sets of group sessions led by trained practitioners that focus on, respectively:

    • people's current mental health and recent experiences in hospital

    • psychoeducation or cognitive behavioural therapy

    • early warning signs and coping strategies.

Peer support

1.5.13 For people being discharged from hospital, consider a group-based, peer-delivered self-management training programme as part of recovery planning. Sessions should:

  • continue for up to 12 weeks

  • be delivered in groups of up to 12 members

  • provide an opportunity for social support

  • cover:

    • self-help, early warning signs and coping strategies

    • independent living skills

    • making choices and setting goals.

1.5.14 Consider providing peer support to people with more than 1 previous hospital admission. People giving peer support should:

  • have experience of using mental health services

  • be formally recruited, trained and supervised.

Care planning to support discharge

1.5.15 Ensure that there is a designated person responsible for writing the care plan in collaboration with the person being discharged (and their carers if the person agrees).

1.5.16 Write the care plan in clear language. Avoid jargon and explain difficult terms.

1.5.17 Ensure the care plan is based on the principles of recovery and describes the support arrangements for the person after they are discharged.

1.5.18 If a person is being discharged to a care home, involve care home managers and practitioners in care planning and discharge planning.

1.5.19 Ensure frequent, comprehensive review of the person's care plan and progress toward discharge.

1.5.20 Send a copy of the care plan to everyone involved in providing support to the person at discharge and afterwards. It should include:

  • possible relapse signs

  • recovery goals

  • who to contact

  • where to go in a crisis

  • budgeting and benefits

  • handling personal budgets (if applicable)

  • social networks

  • educational, work-related and social activities

  • details of medication (see the recommendations on medicines-related communication systems in NICE's guideline on medicines optimisation)

  • details of treatment and support plan

  • physical health needs including health promotion and information about contraception

  • date of review of the care plan.

Preparing for discharge

1.5.21 Mental health practitioners should carry out a thorough assessment of the person's personal, social, safety and practical needs to support discharge. The assessment should include risk of suicide (see recommendations 1.6.6–1.6.8). It should:

  • relate directly to the setting the person is being discharged to

  • fully involve the person

  • be shared with carers (if the person agrees)

  • explore the possibility of using a personal health or social care budget and ensure the person understands about charges for social care

  • cover aftercare support, in line with section 117 of the Mental Health Act 1983

  • cover aspects of the person's life including:

    • daytime activities such as employment, education and leisure

    • food, transport, budgeting and benefits

    • pre-existing family and social issues and stressors that may have triggered the person's admission

    • ways in which the person can manage their own condition

    • suitability of accommodation.

1.5.22 Recognise that carers' circumstances may have changed since admission, and take any changes into account when planning discharge.

1.5.23 Before the person is discharged:

  • let carers know about plans for discharge

  • discuss with carers the person's progress during their hospital stay and how ready they are for discharge

  • ensure that carers know the likely date of discharge well in advance.

1.6 Follow-up support

1.6.1 Discuss follow-up support with the person before discharge. Arrange support according to their mental and physical health needs. This could include:

  • contact details, for example of:

    • a community psychiatric nurse or social worker

    • the out-of-hours service

  • support and plans for the first week

  • practical help if needed

  • employment support.

1.6.2 Consider booking a follow-up appointment with the GP to take place within 2 weeks of the person's discharge. Give the person a written record of the appointment details.

1.6.3 At discharge, the hospital psychiatrist should ensure that:

  • Within 24 hours, a discharge letter is emailed to the person's GP. A copy should be given to the person and, if appropriate, the community team and other specialist services.

  • Within 24 hours, a copy of the person's latest care plan is sent to everyone involved in their care (see recommendation 1.5.20).

  • Within a week, a discharge summary is sent to the GP and others involved in developing the care plan, subject to the person's agreement. This should include information about why the person was admitted and how their condition has changed during the hospital stay.

1.6.4 If the person has a learning disability, dementia or is on the autistic spectrum, the hospital team should lead communication about discharge planning with the other services that support the person in the community. This could include:

  • older people's services

  • learning disability services

  • the home care service.

1.6.5 If a person is being discharged to a care home, hospital and care home practitioners should exchange information about the person. An example might be a hospital practitioner accompanying a person with cognitive impairment when they return to the care home to help their transition (see also sharing information about a resident's medicines in NICE's guideline on managing medicines in care homes).

1.6.6 In collaboration with the person, identify any risk of suicide and incorporate into care planning.

1.6.7 Follow up a person who has been discharged within 7 days.

1.6.8 Follow up a person who has been discharged within 48 hours if a risk of suicide has been identified.

1.6.9 Consider contacting adults admitted for self-harm, who are not receiving treatment in the community after discharge, and providing advice on:

  • services in the community that may be able to offer support or reassurance

  • how to get in touch with them if they want to.

Community treatment orders

1.6.10 Decide whether a community treatment order (CTO) or guardianship order is needed (see the Mental Health Act Code of Practice), based on:

  • the benefit to the person (for example, it may be helpful for people who have had repeated admissions)

  • the purpose (for example, to support the person to follow their treatment plan)

  • the conditions and legal basis.

1.6.11 Ensure that the person who will be subject to the order has the opportunity to discuss why it is being imposed. Explain:

  • the specific benefit for the person

  • how to access advocacy (including their entitlement to an Independent Mental Health Advocate), and what this means

  • what restrictions the order involves

  • when it will be reviewed

  • what will happen if the person does not comply with the order, and that this may not automatically lead to readmission.

1.6.12 Ensure that the conditions, purpose, legal basis and intended benefit of the order are explained to families, carers and others providing support.

  • National Institute for Health and Care Excellence (NICE)