PiC Patient Treatment Timeline Framework Pre-discharge phase PRE-DISCHARGE PHASE


The pre-discharge phase generally takes between 3-6 months though this may vary depending on the patient and their level of security.


Key joint goals of this phase include: • Review of Recovery Care plan with identified next provider • Shared responsibilities between providers to meet rehab needs • Risk taking clarified around outcomes associated with leave and rehab process • Clear leave requirements identified, agreed and evaluated between patient, MDT, Ministry of Justice and next provider • Timeframe identified and agreed


• Joint formation, with patient, of discharge care plan


• Final joint review with patient of recovery tools used (i.e. Recovery Star; Wellness Recovery Action Plans (WRAPS) and/or Developing Recovery Enhancing Environments Measure (DREEM)


• Final review of risk care plan • Final one-to-one sessions with primary nurse • Discharge summary completed by primary nurse • Ensure all property ready for discharge


• Review of physical needs and medication • Review of patient’s mental state and readiness for transfer/discharge • Preparation of documents summarising treatment episode, including CPA/Section 117 meeting and most recent tribunal report • Prescribe medication as appropriate post discharge • Liaison with CMHT or Clinical Team at next placement • Completion of statutory requirements under MHA • Liaison as necessary with Ministry of Justice • Provide discharge summary and ensure contingency and crisis plans are robust


Preparation for the end of therapeutic work and relationships starts as soon as a discharge date is agreed. This final phase of treatment includes:


• Work through with the patient the emotional impact of the ending of the therapy relationship • Jointly review the patient’s progress against therapy targets. This may include a final psychological assessment


• Prepare an end of therapy report and psychology discharge summary; make arrangements for any appropriate follow up with the patient and the receiving service


• Where appropriate arrange attendance at the patient’s next CPA • Relapse prevention plans


• Final individual and or group sessions to reflect on progress so far and review of goal setting for future placement • Final report with summary for patient in accessible format • Compilation of work folders and certificates for new placement


• Final one-to-one sessions with OT in which OT care plans, engagement and progress are reviewed and documented; discharge summary completed by OT


Final review of educational pathway: • Individual session with education coordinator to consolidate accredited learning • Recognise the knowledge and skills developed through educational and vocational work activities • Discuss future education and vocational pathway and complete final individual learning plan identifying further learning needs • Hand over patient’s work folder and individual learning plans


• Inform the nearest relative of transfer/discharge and post transfer/discharge • Liaise with the care coordinator regarding Section 117 arrangements; liaison with MAPPA and probation • Ensure patient monies are prepared for collection/transfer • Final 1:1 session and prepare social work discharge summary • Liaise with social work department in next placement where appropriate; forward information and reports when required • Make arrangements for PiC representation to attend first CPA meeting post discharge


• The patient’s advocate will give final consultation summarising tasks completed and tasks outstanding. Onward advocacy referral if requested.


PATIENT’S ‘SHARED PATHWAY’ SOCIAL WORK


THERAPY, EDUCATION & ACTIVITY


OCCUPATIONAL


SPEECH & LANGUAGE THERAPY


MOVING ON PSYCHOLOGY


PSYCHIATRY & PRIMARY CARE


NURSING


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