Care Pathway Months 12-18

Ending and Discharge

Carefully planned endings underpin the ending and discharge phase of care as individuals move on to further placements or independent living. This final phase of care and intervention aims to encourage independent living and provide opportunity for consolidation of skills training, risk management, self-management and therapy procedures. It also enables supported transition into identified placements or accommodation and establishment of new routines, activities, support networks and social groups.

Therapeutic relationships remain significant and the relational security and secure attachment base that has been the foundation to the care journey now provides a safety net for moving on. Measures and scales will again be reviewed to monitor progress but interventions focus around managing endings, goodbye-focussed interventions and the use of the service as a secure platform to reflect upon the inevitable anxieties about change and moving.

Care plans, risk management plans and positive behaviour support plans will continue to be used to inform relapse prevention and crisis management interventions and the team will work with statutory services and wider support networks to manage risk and promote continuity of care. Endings will remain in the spotlight in order to reduce the predictable risk of abandonment and rejection schemas being activated as discharge approaches.

Brief relapse and increase in risk behaviours are often associated with transition out of placements as attachments are disrupted and new key relationships are formed, difficulties will be managed using a strengths-based approach and least restrictive practice ensuring the individual in our care can feel confident in their abilities.

Vestige will work closely with statutory, community and voluntary organisations to support transition out of services and will offer time-limited follow up and access to a leavers group where appropriate.

  • Vestige Psychiatry Team will:

    Undertake final clinical reviews, assessment of mental health and diagnosis and liaise with statutory psychiatry services to provide comprehensive handover of clinical information and responsibilities. Facilitate a discharge CPA meeting. Review any ongoing mental health act status and community access still in place. Review medication and any self-medication regimes; considering efficacy, tolerance and side effects. Review need for PRN prescriptions and PRN medication plans in the context of discharge planning.

  • Vestige Psychology Team will:

    Use the psychological formulation to guide and supervise the team using a Cognitive Analytic Therapy model of consultation, supporting relational security and symptom and risk management with a specific focus on revision strategies and ending of interventions. Offer ongoing compassion-focussed, needs-led individual therapy that is evidence-based and underpinned by trauma-informed principles focussing on development of goodbye narratives. Continue to facilitate DBT skills-informed group interventions to support consolidation of a range of psychological, interpersonal and practical skills to aid symptom management, relationships and well-being. Invite mental health professionals and carers into a consultation process to enable a joint process, with the person in our care, of sharing understanding, formulation and helpful revisions to support successful discharge. Facilitate therapeutic follow-up and ‘leavers group’ for an agreed, time-limited period after discharge.

  • Vestige Nursing Team will:

    Review mental health, coping strategies, daily living skills, lifestyle, diet, sleep, relationships and sexual health in order to inform final interventions, support consolidation of skills and enable final discharge arrangements and plans. Collaboratively review risk assessments and plans in the context of the psychological formulation to inform relapse prevention and crisis planning that will follow the individual as they leave Vestige Healthcare Services. Continue to support the MDT in positive risk taking; championing least restrictive practice throughout the discharge journey. Continue to work within a psychologically-informed model of care undertaking symptom management interventions as needed, promoting self-management. Support use the DBT protocol ‘Chain Analysis’ to promote individuals’ ongoing understanding, recognition and revision of challenging and risky behaviours. Review, with the support of the Psychiatry team, self-medication procedures. Review wider plans of care, updating positive behaviour support strategies and maintaining hope for discharge.

  • Vestige Occupational Therapy Team will:

    Support consolidation of occupational functioning, activities and interests in the context of the psychological formulation and discharge plans. Generate discharge plans in the context of impact assessments and review scales and measures undertaken on admission to inform the need for community support. Provide support with self-management of weekly activity plans and remain encouraging and aspirational in developing individuals’ occupational skills opportunities. Work closely with those in our care to cement meaningful, social, educational, recreational and relaxation focussed activities that can be maintained after discharge. Maximise relationships with community and voluntary organisations and undertake community visits once move-on accommodation has been identified to optimise occupational opportunities in the discharge area. Support independence with budgeting, menu planning, shopping and cooking. Using a solution-focussed approach support established skills for independent living such as bill paying, prescription collection, banking etc.to ensure confidence in independent living.

  • Vestige Support Staff will:

    Continue to work within a psychologically-informed, Cognitive Analytic model, within the MDT to use therapeutic relationships to support a positive discharge by following specific, evidence-based, plans of care. Continue to implement Occupational Therapy schedules and plans, actively encouraging people in our care to use the skills coaching provided and promoting increasing independence and self-management.