Transition planning and hospital discharge – helping people with LD and behaviours of concern

Transition Planning and Hospital Discharge

Helping people with learning disabilities and behaviours of concern move out of hospital

iriscaregroup.co.uk

Dr Hayley Thomas, Consultant Clinical Psychologist

• Service context

• Current discharge challenges

• Assessment

• Intervention pathways

• Discharge planning

• Transition support

• Lessons learned Aims

Service context and patient group

• Pinetree Hospital

• Locked rehabilitation hospital

• Adults with complex needs

• Trauma history

• Changing presentation of patient group

• Step down pathways

Discharge challenges

• Suitable community provision

• Commissioning

• Complex legal processes

• Patient considerations

• Readiness for discharge vs readiness for discharge planning

• When to begin……….

• Comprehensive multidisciplinary assessment

• Clinical and forensic evidence base

• Cognitive and functional skills assessment

• Structured professional judgement risk assessments:

• HCR-20

• ARMIDILO-S

• RSVP

• Quality of life

Formulation

Individualised discharge goals

Intervention

• Positive Behaviour Support model of care

• Goal setting: Building Better Lives

• Pharmacology

• Bespoke, person-centred, evidence-based

• 5 pathways

• Rehabilitation

• Complex behaviour

• Complex Autism Spectrum Condition

• Adapted Dialectal Behaviour Therapy

• Forensic

Discharge Planning

Considerations:

• Service spec

• Individual wishes

• Managing expectations

• Legal framework

• Capacity and need for supervision

• Support needs

• Restricted patients

• Restriction vs community living

• Crisis planning

Transition support

• Co-production

• Network training

• Advocacy and family

• PBS translation

• Training

• Flexibility and responsivity

• Ongoing………..

Lessons learned

• Adapting to the changing landscape

• Knowledge is key

• Discharge planning from the start

• Accepting therapeutic limits

• Working with the system

• Getting ducks in order

• Sharing practice is essential

Complex discharges can be successful