Care Pathway Months 3-9

Assessment and Intervention Phase

During the assessment and intervention phase continuing assessment of need and the effectiveness of planned recovery-focussed interventions is key to a successful care journey.

Therapeutic relationships will be consolidated through needs-led care strategies and person-centred interventions. Initial assessments and scales will be reviewed alongside self-report measures to assess effectiveness of interventions and identify further personalised goals.

Risk behaviours prevalent during the transition period will be better understood and positive behaviour support plans and therapeutic interventions will be targeted to recognising and revising risk behaviours.

Discharge remains a focus to reduce the risk of dependence, whilst prioritising co-production.

  • Vestige Psychiatry Team will:

    Undertake clinical review including assessment of mental health and diagnosis, at a minimum of 4 weekly intervals. Collaboratively review mental health act status and community access with the aim of safely and collaboratively reducing restrictions at the earliest possible opportunity. Review medication with the aim of meaningful service user involvement considering efficacy, tolerance and side effects. Review PRN and rapid tranquilisation prescriptions and plans. Chair CPA meeting to document progress.

  • Vestige Psychology Team will:

    Develop the preliminary formulation to offer a fuller, trauma-informed understanding of the predisposing, precipitating, perpetuating and positive factors an individual is experiencing to guide and supervise the team using a Cognitive Analytic Therapy model of consultation, supporting relational security and symptom and risk management. Offer compassion-focussed, needs-led individual therapy that is evidence-based and underpinned by trauma-informed principles. Facilitate weekly DBT skills-informed group interventions to support development of a range of psychological, interpersonal and practical skills to aid symptom management, relationships and well-being.

  • Vestige Nursing Team will:

    Continually review mental health, coping strategies, daily living skills, lifestyle, diet, sleep, relationships and sexual health. Collaboratively review risk assessments and plans in the context of the psychological formulation and support the MDT in positive risk taking; championing least restrictive practice. Continue to work within a psychologically-informed model of care undertaking symptom management interventions. Support delivery of DBT skills-informed group interventions. With psychology supervision use the DBT protocol of ‘Chain Analysis’ to promote understanding, recognition and revision of challenging and risky behaviours. Review initial plans of care, updating positive behaviour support strategies and maintaining aspirations for discharge.

  • Vestige Occupational Therapy Team will:

    Review occupational functioning, activities and interests in the context of an established placement and psychological formulation. Undertake impact assessment and review scales and measures undertaken on admission. Review and revise weekly activity plans to reflect current functioning and remain aspirational in developing occupational skills and opportunities. Work closely with those in our care to support meaningful, social, educational, recreational and relaxation focussed activities. Maintain relationships with community and voluntary organisations to optimise occupational opportunities. Begin interventions to support development of budgeting, menu planning, shopping and cooking.

  • Vestige Support Staff will:

    Continue to work within a psychologically-informed, Cognitive Analytic model, within the MDT to use therapeutic relationships to maximise recovery opportunities by following specific, evidence-based, plans of care. Implement Occupational Therapy schedules and plans. Actively engage with people in our care to provide skills coaching, promoting independence and self-management when opportunity allows.