How We Reduce the Reliance On Long-Term Hospital/Secure Settings

Transitioning from hospital or secure care providers back to community settings can be a challenging time for the individual and loved ones. We work collaboratively when supporting people with the move and there are three key areas that we focus on to achieve a successful transition.

Effective Communication

• When changing care providers, level of support or location, it is vitally important to communicate effectively with the individual, their family and care professionals, to ease any concerns or anxieties and ensure that all needs are met through a smooth transition.
• Our person-centred approach enables the individual to feel part of the journey and have a meaningful involvement at every stage. We flex the pace of change to the individual’s ability to cope, which results in a greater likelihood of successful transition. Therefore, the sooner we can be involved in the planning phase, the better for all, as we create open and regular communication pathways for those involved.

Creating the Right Support

• Every transition process is different, unique to the individual, and finding the right care package, team and accommodation can be a complex process. Some people are ready to move relatively quickly and for others, the process may take months to get familiar with new surroundings and care providers.
• Creating a package of care is a fine balance between taking the time to develop appropriate, quality support and not taking too long to put this in place, otherwise, it could have a detrimental impact on the individual’s mental health. This is why effective communication is critical across all parties so that everyone is aware of achievable timescales.
• Our care teams are selected for their personal characteristics and life experience as much as their career experience and qualifications. Values are important to us, which is why our people have the right approach, level of compassion, empathy and attitude to deliver quality care.
• The supervision and support we provide our front line personnel, enable us to deliver resilient and sustainable care with a reliable team.
• We are dedicated to continuous improvement and developing our partnership and person-centred approach, to ensure we provide quality support in the right environment for the individual.

Robust Transition Planning

• Our holistic approach to transition planning involves everyone at the right time and at the right stage. Ensuring sustainable support when a person moves is one of the critical factors for robust transition planning and through our collaborative, multi-agency approach we can put contingency and relapse prevention plans in place in good time to respond to warning signs and avoid crisis situations.
• At the beginning of any transition journey, we investigate what a good transition looks like for the individual, such as when it’s best to introduce a new care team before a move – this is often a gradual process. We monitor the individual’s engagement and wellbeing during the process to ensure we avoid support breakdowns and have the most appropriate team in place. We focus on really understanding the person through regular briefings with multi-agency teams and shadow hospital teams to learn about the big and little things that matter.

The Carebright Model of Care

Our model of care and support is a person-centred outcome based approach. Working directly with the individual, we will identify clear and achievable pathways to support people on their road to recovery. The Recovery Star approach will promote involvement and motivate individuals to develop their own coping strategies.

What Does this mean for the funder ? We do not believe that people who have experienced or are experiencing Mental Health problems need to be “stuck” in the system. We can facilitate and support early discharge from hospital or indeed prevent admission. Our enabling approach develops the levels of resilience for individuals which goes some way to preventing breakdown or crisis in the community which may lead to their readmission. In short, we will demonstrate that in the medium and long term funding costs will be lower than they would be if our service wasn’t there to support people.