1. Improved Transitions and Discharge Task and Finish Group
Phil Coombes & Amy Spencer
Clinical Director Elysium Healthcare & Ward Manager Lincolnshire Partnership

2. Why are we looking at transitions?

3. Aims of Group
Ensuring smoother transitions between inpatient services and community
Reducing unnecessary delays in the person’s stay
Improving discharge arrangements
Keep the service user key to the journey of discharge
Clearer goals / routes to discharge

5. Key Tasks and Progress so far
Ending the need to carry out an access assessment at every potential change in level of security- what process will be put in place to avoid the need for this?
Discussions between the group of identifying the full pathway at admission using home area and service user need / requests to propose initial pathway needed a more joined up team
Developing a “decision tree” to support transition
Reviewing the tree developed by admissions group and to adapt to fit levels of security, all levels of security leads identified to complete a basic expectation to move to next level to be shared with service users from the start to know what is needed next to achieve a move

6. Oversight of prison model pilot development
CFS working more assertively with people in inpatients and support transition into the community (assertive transitions team)
Update from submitted bid and close working with this task and finish, as with admission task and finish group to ensure smoother ways in and out of forensic services, and integration with units locally
Oversight of prison model pilot development
We now have representative from offender health attending and they are looking at current ways of referral in to services at correct levels using decision tree and guidance being developed, to help ensure appropriate and timely placement

7. Key tasks and progress so far
“Blending” levels of security eg oversight of the Women’s Pilot in this group
Awaiting feedback from start of the pilot to see what can be learnt, can this be done at other levels i.e low and step down (funding crossover)
More assertive/ proactive discharge processes and pathways: Single Point of Exit?
The use of the Hub discussed at the other task and finish groups to allow full overview through services and out incorporating the assertive in reach team trigger points for key people to attend from receiving services sign up by teams for attendance at 6 month pre discharge point (with RC’s attendance from the community at final step out?)

8. How it feels at the moment

9. Roles of the Hub for transitions
Really need to get this part right !
Oversight of beds across all geographical areas
Nearly there
Awareness of all units location and specialities
(now submitted and in place)
Central component to ensure all parties are aware and triggered at right time via CPA process to allow for more joined up step down
Work to be done and agreement of who
Can we move case managers straight over as they have existing knowledge ?

10. What will we use to know its working ?
Better experience for the service user and family; ensuring choice, locality and involvement are fundamental principles
Reduction in duplication (right people right place right time)
Reduction in LOS
More transparent processes
Better support in terms of transition into the community and relapse prevention
A more responsive and joined up forensic MH system

11. Where are we now?

12. Where are we now?
Key clinicians identified at all levels of security identified and attending
Links to admissions and community forensic teams task and finish groups to ensure liked up process
Existing standards / process received from NHSE as a starting point re Levels / standards of security identified (not re-inventing the wheel)
Use existing good practice to help produce the most integrated way forward (Lincolnshire process meeting discussed with CCG attendance to assist in all steps)

14. Group work tasks (what we need help with/ what have we missed?)
1. What makes a good transition?
Consider this in terms of both up and down levels of security

15. Group work tasks (what we need help with/ what have we missed?)
2. How can we use the Care Programme Approach (CPA) process more effectively to facilitate transition?
Consider this in terms of what works well and areas that could be improved

16. Group work tasks (what we need help with/ what have we missed?)
3. Should IMPACT look at developing a Personal Passport to support transition? Consider how can it facilitate transition and what should it contain?