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Transition between community or care home and inpatient mental health settings

About

What is covered

Poor transition between inpatient mental health settings and community or care home settings has negative effects on people using services and their families and carers. In particular, lack of integrated and collaborative working between mental health and social care services, and between practitioners based in hospitals and those in the community, is a key issue.
This interactive flowchart is about everyone who uses mental health inpatient facilities, including children, young people and adults, and people who have other health issues and care needs. It primarily covers transitions – admissions and discharges – and makes recommendations about how they might be handled in order to maximise the benefits of the treatment being offered, and continuity of care. It includes people who are admitted from, or discharged to, care homes and other community settings. The flowchart also covers the preparation for discharge that takes place during the inpatient stay.

Updates

Updates to this interactive flowchart

11 September 2017 Transition between inpatient mental health settings and community or care home settings (NICE quality standard 159) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on transition between community or care home and inpatient mental health settings in an interactive flowchart

What is covered

Poor transition between inpatient mental health settings and community or care home settings has negative effects on people using services and their families and carers. In particular, lack of integrated and collaborative working between mental health and social care services, and between practitioners based in hospitals and those in the community, is a key issue.
This interactive flowchart is about everyone who uses mental health inpatient facilities, including children, young people and adults, and people who have other health issues and care needs. It primarily covers transitions – admissions and discharges – and makes recommendations about how they might be handled in order to maximise the benefits of the treatment being offered, and continuity of care. It includes people who are admitted from, or discharged to, care homes and other community settings. The flowchart also covers the preparation for discharge that takes place during the inpatient stay.

Updates

Updates to this interactive flowchart

11 September 2017 Transition between inpatient mental health settings and community or care home settings (NICE quality standard 159) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Transition between inpatient mental health settings and community or care home settings

These quality statements are taken from the transition between inpatient mental health settings and community or care home settings quality standard. The quality standard defines clinical best practice in the transition between inpatient mental health settings and community or care home settings and should be read in full.

Quality statements

Access to independent advocacy services

This quality statement is taken from the transition between inpatient mental health settings and community or care home settings quality standard. The quality standard defines clinical best practice in the transition between inpatient mental health settings and community or care home settings and should be read in full.

Quality statement

People admitted to an inpatient mental health setting have access to independent advocacy services.

Rationale

Having an advocate helps people to make their views and wishes heard. It is important that people are told about independent advocacy services on admission to an inpatient mental health setting, and can access them throughout their stay, so that they can be involved in decisions about their care.

Quality measures

Structure
a) Evidence of local arrangements to provide independent advocacy services for people admitted to an inpatient mental health setting.
Data source: Local data collection, for example, service level agreements with local advocacy service providers and hospital admission checklists.
b) Evidence of local arrangements to promote independent advocacy services to people admitted to an inpatient mental health setting.
Data source: Local data collection, for example, admission checklists.
Process
Proportion of admissions to an inpatient mental health setting for which information is provided on admission about support available from independent advocacy services.
Numerator – the number in the denominator for which information is provided on admission about support available from independent advocacy services.
Denominator – the number of admissions to an inpatient mental health setting.
Data source: Local data collection, for example, an audit of case notes.
Outcome
Level of satisfaction with access to independent advocacy services for people using inpatient mental health settings.
Data source: Local data collection, for example, local patient surveys.

What the quality statement means for different audiences

Service providers (inpatient mental health services) ensure that independent advocacy services are available to people on admission. Staff know how to signpost people to independent advocacy services at admission or at any point during their stay in a way that takes account of individual needs and preferences.
Health and social care practitioners (the admitting team) discuss independent advocacy services with people on admission to an inpatient mental health setting and tell them how to access services if and when they want to.
Commissioners (local authorities) ensure that they commission adequate independent advocacy services and that access to independent advocacy is set out in contracting arrangements with providers so that people admitted to an inpatient mental health setting have access to independent advocacy services on admission and during their stay.
People who are admitted to hospital for a mental health problem are told how they can get support from an independent advocacy service, if they want to. An independent advocate can help people get the information they need to make choices about their care and can help them to get their views across.

Source guidance

Definitions of terms used in this quality statement

Independent advocacy services
Advocacy is taking action to help people say what they want, secure their rights, represent their interests and obtain services they need. Advocates and advocacy schemes work in partnership with the people they support and take their side. Advocacy promotes social inclusion, equality and social justice.
Independent advocacy services include, but are not limited to:

Equality and diversity considerations

Independent advocacy services, and information provided about them, should take into account people’s language and communication needs, cultural and social needs, and other protected characteristics.

Out-of-area admissions

This quality statement is taken from the transition between inpatient mental health settings and community or care home settings quality standard. The quality standard defines clinical best practice in the transition between inpatient mental health settings and community or care home settings and should be read in full.

Quality statement

People admitted to specialist inpatient mental health settings outside the area in which they live have a review of their placement at least every 3 months.

Rationale

People should be treated for a mental health problem in a location that helps them to retain the contact they want with family, carers and friends, and to feel as familiar as possible with the local environment. If people with a non-acute mental health problem are admitted to a specialist inpatient mental health setting outside the area in which they live, they are particularly vulnerable to delayed discharges because case management and assessment of readiness for discharge is more difficult to deliver. When people are placed outside of the area in which they live, named practitioners from the person’s home area and the inpatient ward can work together to ensure the placement is reviewed regularly, so that it does not last longer than necessary.

Quality measures

Structure
a) Evidence of local arrangements to monitor the length of placements of people admitted to a specialist inpatient mental health setting outside the area in which they live.
Data source: Local data collection, for example, identification systems.
b) Evidence of local arrangements to review placements at least every 3 months for people in an out-of-area placement in a specialist inpatient mental health setting.
Data source: Local data collection, for example, review protocols.
Process
Proportion of out-of-area placements in specialist inpatient mental health settings for which there is a review of the placement at least every 3 months.
Numerator – the number in the denominator for which there is a review of the placement at least every 3 months.
Denominator – the number of out-of-area placements in specialist inpatient mental health settings lasting longer than 3 months.
Data source: Local data collection, for example, from hospital patient records.
Outcome
a) Number of active out-of-area placements in specialist inpatient mental health settings.
Data source: Local data collection.
b) Length of stay in out-of-area placements in specialist inpatient mental health settings.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (specialist inpatient mental health services, such as those in high-dependence units or specialised rehabilitation units within the NHS or independent services) ensure that they work together to monitor the length of placements for people in an out-of-area placement in an inpatient mental health setting, so that named practitioners from the inpatient ward and the person’s home area can review the placement at least every 3 months.
Health and social care practitioners (a named practitioner from the person’s home area and a named practitioner from the ward) work together to monitor the length of placements of people admitted to specialist inpatient mental health settings outside the area in which they live and review these at least every 3 months.
Commissioners (clinical commissioning groups) ensure that placements are monitored and reviewed at least every 3 months when people are admitted to specialist inpatient mental health settings outside the area.
People who are admitted to a specialist mental health hospital outside the area where they live have a review of how their placement is going at least once every 3 months, to make sure they are not kept in hospital for longer than they need to be. This is carried out jointly by a person from the hospital ward and someone from their home area involved in their care.

Source guidance

Definitions of terms used in this quality statement

Placement review
Named practitioners from the person's home area and the inpatient ward should work together to ensure that the person's current placement lasts no longer than required. Review should be carried out either in person or by audio or videoconference.
Specialist inpatient mental health setting outside the area in which the person lives
In this quality statement, a specialist mental health inpatient setting refers to an inpatient unit that provides non-acute complex care and does not form part of the usual local network of services. This means that it does not usually admit people living in the catchment of the person’s local community mental health service and is somewhere the person cannot be visited regularly by their care coordinator to ensure continuity of care and effective discharge planning. Sending providers are to determine if a placement is classed as an out-of-area placement.
Examples of specialist mental health inpatient settings include high-dependence units or specialised rehabilitation units within the NHS or independent services. People admitted to specialist inpatient settings will often have multiple mental health problems.

Communication on discharge

This quality statement is taken from the transition between inpatient mental health settings and community or care home settings quality standard. The quality standard defines clinical best practice in the transition between inpatient mental health settings and community or care home settings and should be read in full.

Quality statement

People discharged from an inpatient mental health setting have their care plan sent within 24 hours to everyone identified in the plan as involved in their ongoing care.

Rationale

Sharing a person’s care plan with people who will be involved in their ongoing care (as agreed by the person and their families or carers, and identified in their care plan) at the point at which they are discharged from inpatient mental health settings helps to make sure agreed plans are received as early as possible, so that they can be carried out and treatment continued. This reduces the risk of avoidable harm to the person, as well as avoidable readmissions.

Quality measures

Structure
a) Evidence of local arrangements to develop care plans that detail who will be involved in providing ongoing care to people discharged from an inpatient mental health setting.
Data source: Local data collection, for example, care planning protocols.
b) Evidence of local arrangements to send within 24 hours, the care plans of people discharged from an inpatient mental health setting to everyone identified in it as involved in their ongoing care.
Data source: Local data collection, for example, hospital discharge protocols.
Process
Proportion of discharges from an inpatient mental health setting where the person’s care plan is sent within 24 hours to everyone identified in it as involved in their ongoing care.
Numerator – the number in the denominator in which the person’s care plan is sent within 24 hours to everyone identified in it as involved in their ongoing care.
Denominator – the number of discharges from an inpatient mental health setting.
Data source: Local data collection, for example, a review of patient notes.
Outcome
a) Level of satisfaction with support following discharge from inpatient mental health settings.
Data source: Local data collection, for example, local patient surveys.
b) Readmissions to inpatient mental health services within 30 days of discharge.
Data source: Data on unplanned readmissions to mental health services within 30 days of a mental health inpatient discharge in people aged 17 and over are available from the NHS Digital Indicator Portal as part of the clinical commissioning group outcomes indicator set – indicator 3.16.

What the quality statement means for different audiences

Service providers (inpatient mental health services) ensure that staff receive training on how to develop care plans, and how to share them so that people involved in care to receive them as early as possible. They have protocols in place to ensure that plans are developed at the earliest opportunity after admission, and shared in a way that allows quickest receipt following discharge, including for people whose admission lasts less than 7 days.
Healthcare practitioners (mental health practitioners) work with people admitted to an inpatient mental health setting to identify people who will be involved in the person’s care and send a copy of the care plan to them within 24 hours of their discharge, using the method of sharing that allows the plan to be received as early as possible. It is important that plans are developed at the earliest opportunity after admission, and shared following discharge, including for people whose admission lasts less than 7 days.
Commissioners (clinical commissioning groups and local authorities) ensure that care plans can be shared within and across health and social care services within 24 hours of people being discharged from an inpatient mental health setting.
People leaving hospital after inpatient treatment for a mental health problem have a care plan for staying as well as possible in future, that they have helped to put together. The plan includes their recovery goals, how to cope with symptoms, what to do in a crisis, their medicines and treatment, and any work, training, learning or social activities. Their mental health practitioner should make sure a copy of this plan is sent within 24 hours of their discharge to everyone who will be involved in supporting them.

Source guidance

Definitions of terms used in this quality statement

Care plan
A care plan for discharge from an inpatient mental health setting is based on the principles of recovery and describes the support arrangements for the person after they are discharged. It should include:
  • discharge address
  • possible relapse signs
  • recovery goals
  • who to contact
  • where to go in a crisis
  • budgeting and benefits
  • handling personal budgets (if applicable)
  • social networks
  • educational, work-related and social activities
  • details of medication
  • details of treatment and support plan
  • physical health needs including health promotion and information about contraception
  • date of review of the care plan
  • follow-up requirements following discharge, including method of communication for follow-up.
It is important that the process of care planning is person-centred and that people are involved in developing their own care plan (see quality statement 8 in the quality standard for service user experience in adult mental health services).
[NICE’s guideline on transition between inpatient mental health settings and community or care home settings, recommendation 1.5.20 and expert opinion]
Everyone involved in a person’s care
People involved in providing support to the person at discharge from an inpatient mental health setting and afterwards should be listed in the care plan. This is likely to include the person’s GP, community mental health teams (including crisis teams), social workers and other local authority services, and carers.
[Adapted from NICE’s guideline on transition between inpatient mental health settings and community or care home settings, recommendation 1.5.20 and expert opinion]

Equality and diversity considerations

In some cases, it might not be appropriate to fully involve people in developing their own care plan, or to share the plan with them, for example when a person lacks capacity. Independent advocates can represent people’s interests and support them to obtain the services they need.

Suicide risk

This quality statement is taken from the transition between inpatient mental health settings and community or care home settings quality standard. The quality standard defines clinical best practice in the transition between inpatient mental health settings and community or care home settings and should be read in full.

Quality statement

People who have a risk of suicide identified at preparation for discharge from an inpatient mental health setting are followed up within 48 hours of being discharged.

Rationale

Mental health practitioners should assess people’s risk of suicide when preparing for discharge. This will take into account the person’s risk on admission to the unit, throughout their stay and when discharged into the community. Everyone discharged from an inpatient mental health setting should receive follow-up, which should be within 48 hours for people who have a suicide risk identified. Follow-up can help to identify any further support they may need, such as access to a crisis service or other community support.

Quality measures

Structure
a) Evidence of local arrangements to identify people at risk of suicide at preparation for discharge from an inpatient mental health setting and to record the risk for 48-hour follow-up.
b) Evidence of local arrangements to follow-up within 48 hours of discharge people who are identified as being at risk of suicide.
Data source: Local data collection, for example, hospital discharge protocols.
Process
Proportion of discharges from an inpatient mental health setting in which people are followed up within 48 hours of discharge if they are identified as being at risk of suicide.
Numerator – the number in the denominator followed up within 48 hours of discharge.
Denominator – the number of discharges from an inpatient mental health setting of people identified as being at risk of suicide.
Data source: Local data collection, for example, an audit of case notes or care plans.
Outcome
Number of suicides of people recently discharged from inpatient mental health settings.
Data source: National numbers of suicides within 3 months of inpatient discharge are published in the University of Manchester’s National confidential inquiry into suicide and homicide by people with mental illness reports.

What the quality statement means for different audiences

Service providers (inpatient mental health settings) ensure that staff are trained to assess and monitor people’s risk of suicide on admission to the unit, throughout their stay and when they are preparing for discharge into the community. They also ensure that staff are trained to follow-up people who are identified as being at risk of suicide within 48 hours of discharge, and that this follow up takes place.
Healthcare practitioners (mental health practitioners) work together to assess and monitor people’s risk of suicide on admission to the unit, throughout their stay and when they are preparing for discharge into the community. They follow-up people within 48 hours of discharge from an inpatient mental health setting if they are identified as being at risk of suicide when preparing for discharge.
Commissioners (clinical commissioning groups) ensure that the services they commission have protocols in places to identify suicide risk throughout an admission and prior to discharge, and follow-up people at risk of suicide within 48 hours of discharge.
People leaving hospital after inpatient treatment for a mental health problem are contacted by someone from their care team to check how they are doing within 48 hours of their discharge, if the team are worried that they may be at risk of harming themselves.

Source guidance

Definitions of terms used in this quality statement

Follow-up
The communication method used for follow-up should be agreed in the person’s care plan.

Equality and diversity considerations

Follow-up may be more difficult for people who are homeless. This should be taken into account when considering discharge into the community. Housing needs should be discussed and arrangements for follow-up made before the person is discharged.

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Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Practitioners involved in admission should refer to crisis plans and advance statements when arranging care.
Practitioners involved in admission and discharge should always take account of carers' needs, especially if the carer is likely to be a vital part of the person's support after discharge.
Education sessions for people affected by mental illness and their families and carers. Psychoeducation uses shared learning to empower people to cope better. Sessions can cover areas such as recognising symptoms and triggers, preventing relapses and developing coping strategies. Carers learn how best to support the person. Sessions typically start while the person is in hospital and run beyond discharge so the person can test approaches in their home setting
There is no single definition of recovery for people with mental health problems, the guiding principle is the belief that it is possible for someone to regain a meaningful life, despite serious mental illness. In this interactive flowchart it is used to refer to someone achieving the best quality of life they can, while living and coping with their symptoms. It is an ongoing process whereby the person is supported to build up resilience and set goals to minimise the impact of mental health problems on their everyday life.
In collaboration with the person, identify any risk of suicide and incorporate into care planning.

Glossary

carers are people who helps another person, usually a relative or friend, in their day-to-day life; this is not the same as someone who provides care professionally or through a voluntary organisation
a carer is someone who helps another person, usually a relative or friend, in their day-to-day life; this is not the same as someone who provides care professionally or through a voluntary organisation
coping strategies are the methods a person uses to deal with stressful situations; the term is used in this interactive flowchart to refer to ways that people cope with their mental illness or related symptoms, some coping strategies can have negative consequences for a person using them or for the people around them
a short document that includes the details of a person's current prescription, the reasons for any changes in medicines, and their immediate medication treatment plan
a summary of what happened during a person's admission and hospital stay from a medical perspective: it must include the diagnosis, outcomes of investigations, changes to treatment and the medicines started or stopped, or dosage changes and reasons why
an intervention in which a healthcare professional observes and maintains contact with a person using mental health services to ensure that person's safety and the safety of others; there are different levels of observation depending on how vulnerable to harm the person is considered to be
relationships based on mutual trust, kindness and respect, focusing on the person's recovery goals

Paths in this pathway

Pathway created: August 2016 Last updated: September 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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