Team’s success in supporting mental health patients at home

SWIFT action by NHS staff and the creation of a transition support team helped more adults with enduring mental health difficulties stay supported at home - reducing hospital stays.

Early in lockdown, a new community enhanced rehabilitation team (Cert) was developed in the wake of a successful response to the national call for action to support mental health rehabilitation patients in the safest place possible.

Staff from mental health rehabilitation wards at Stewart House and The Willows in Leicester acted promptly to speed up, where appropriate, the discharge of mental health rehabilitation patients who might otherwise need up to 15 months’ inpatient care.

The wards redeployed staff to create a “community transition support team”, providing a 12-week “bridge” between hospital and community services, delivering:

■ Evidence-based psychological interventions to reduce anxiety following transition from inpatient to community setting;

■ A link with community groups, vocational opportunities and educational courses to help with community integration;

■ Support to develop and practise useful skills around daily living;

■ Help to build confidence and independence in getting support locally.

Kelly Fenton, consultant psychologist and clinical lead for the new team, said: “We were aware that service users might feel anxious about an early transition from hospital to the community and the creation of the transition support team helped to allay that anxiety while helping service users link in with the local community and reducing the risk of readmission to hospital.”

The initial evaluation of the new team found no readmissions to hospital in the early weeks post discharge, 50 per cent of service users reported reduced anxiety with a further 25 per cent not seeing an increase in anxiety during their transition to the community. One service user, Ryan, said: “When I first got referred to the Cert team, I had been in hospital for a long period and I didn’t really feel like I had an identity. I felt low and didn’t know which direction my life was going in. The Cert team helped me to build up confidence and a good support network. “Coming back into the community felt scary at first and my anxiety levels were quite high and I didn’t know where to turn to, but the Cert team stuck with me and helped me to find the person I am today. “They gave me tips and techniques to reduce my anxiety, such as meditation.”

Earlier this year, the team was expanded and now offers enhanced rehabilitation interventions within a community setting, allowing service users to access services in the least restrictive setting.

The community team links in with key community partners in local authorities, supported housing and third sector agencies to make shorter inpatient stays a reality for more people with severe and enduring mental health needs.

The multi-disciplinary team includes psychologists, mental health nurses, medics and occupational therapists and will soon be recruiting peer support workers with lived experience.

Kelly said: “This initiative is research-led, recovery-focused and developed in collaboration with service users, and has shown good outcomes throughout the pandemic, allowing us to work with colleagues in other teams to increase people’s quality of life in the community.

“We are demonstrating that people don’t need to be in a bed to receive care and we’re working to ensure people receive continuity of care and the best outcomes.”

A paper by the team on the early response has now been published by the British Journal of Mental Health Nursing with a further paper due to be published early this year.

We are demonstrating people don’t need to be in a bed to receive care and we’re working to ensure people receive continuity of care