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Inpatient neuro rehab

Ending the ‘revolving door’ of failed discharges

Through the Assertive Transitions Service, inpatients are being supported to achieve sustainable discharges into the community



Through the creation of the Assertive Transitions Service initiative, inpatients are being supported to overcome the barriers that are preventing them from being discharged from hospital and reintegrating back into independent or supported living in the community. 

Here, NR Times learns more about the pioneering project, its positive impact on delivering sustainable discharges, and the potential for it to be rolled out in more locations across the country


For a vast number of patients in a hospital setting, being able to live an independent life in the community is their ambition. But actually achieving that can be hugely challenging. 

The process of discharging from a hospital setting into the community has long been fraught with potential pitfalls. Is the person ready psychologically as well as physically? Are the right things in place for their reintegration? Will they be able to cope? 

In many instances, the lack of success in their discharge lies in this uncertainty and lack of effective planning with patients feeling unprepared for their new life beyond the safety of their inpatient surroundings, and often they end up staying or returning there.

But through the creation of the Assertive Transitions Service (ATS), the longstanding barriers preventing patients from being able to live successfully in the community are being tackled. This involves providing a tailored package of support which promotes the recovery of patients residing in hospital, which allows them to  move directly from a hospital to a community, whilst being able to live a meaningful life and avoiding readmission.  

The ATS initiative, created by the East Midland Provider Collaborative (IMPACT) – which brings together the NHS with partners including St Andrew’s Healthcare, Rethink Mental Illness and Framework – is working successfully across the region, supporting a person in hospital for up to 12 months prior to their discharge, and often up to the same length of time once they have moved back into the community. 

Certainly, its impact is being felt by people who have been trapped in the ‘revolving door’ of failed discharges. 

For 49-year-old Helen, who has been involved with statutory services since the age of 14, she credits the service with making the meaningful difference in her being able to achieve the independence she has always hoped for. She has now been living in the community for almost two years. 

“I didn’t have much faith in the authorities….I thought if that service can’t help me, then how can this one? I think the issues moving from hospital to the community is the lack of the ‘in between’,” says Helen. 

“ATS offer the educational side, they’ll help you with life skills, bank accounts and activities. They helped me realise the community was a safe place. 

“They’ve got me to a stage now where I know it’s OK to be in the community. You do belong. My life is worth living in the community.”

Currently focusing on discharges from secure inpatient settings directly into the community, the success of the scheme is now seeing it considered for other patients – including those in a neurological care environment – and those living in other parts of the country. 

Through its partner working approach and bespoke support, ATS is helping to address key issues, which have previously been barriers to sustainable discharges. 

‘We’ve got one key goal, which is making sure that we reduce the length of stay for patients, by  proactively supporting them and meeting their individual needs,” says Dr Tawanda Pendeke, clinical team lead at St Andrew’s Healthcare, based in Northampton. 

“ATS is s a psychosocial model which ensures through collaboratively working with inpatient and community services that patients are integrated seamlessly back into the community through provision of intensive transitional support. 

“This has been designed purposely because we know the challenges of the ‘revolving door’ patients. And through ATS, we can support them with the stresses they may face. 

“As a wraparound service, we are addressing key issues from a recovery perspective – we focus on the clinical recovery, which means we provide in reach support to the inpatient services in assessing readiness for discharge, alongside the social recovery, which means we then link in and signpost patients to the relevant stakeholders  in the communities. 

“What this translates to for patients is gaining the social capital they need, and ensuring that relationships with families or people identified in their support network are positive. Where personal recovery is concerned, our team engage the individuals in strength based interventions to help rediscover self – for instance, area of focus could be around character strengthening. 

“All the programmes are individualised to meet the needs of the patient, and there is a concerted effort by all partners involved in making sure that a patient transitions smoothly.”

The multi-faceted approach sees lengthy planning and support both pre- and post-discharge, which is helping to ensure its success.

“We understood that building therapeutic relationships with a patient before discharge is very important,” says Dr Pendeke 

“There was a gap where discharge and re-integration in the community is concerned, which patients had identified through co-production groups, and we realised there was a lack of support to help them with the transition. 

“As a service, we identified that building therapeutic relationships prior to discharge was integral to the transition process. This is because having a familiar face pre- and post-discharge would help mitigate some of the challenges which they encounter, knowing we are there for them depending on their lifeworld needs for up 12 months.”

And through the stories of patients such as Helen, who had long felt unsupported both before and after discharge, the involvement of ATS has proved transformational for her. 

“With Helen, she had previously moved from one secure service to another, with not much changing for her. But when she came to ATS, I think it  reduced ‘gate fever’ for her,” says Angela Ncube, pathway navigator at St Andrews Healthcare. 

“She is coming up to two years now since her discharge, and it hasn’t all been smooth sailing and there have been a few hiccups here and there, but she has been able to maintain her independence in the community in a way both herself and her family didn’t think was possible. Even I, as a clinician, looking at the paperwork and the history, was questioning whether it would work. 

“But I think the success has come from having appropriate support mechanisms in place and how well we have come to know Helen. Aligning the right clinician with a particular patient is also hugely important. 

“Knowing her triggers and knowing how to support her through difficult periods, being able to read the unspoken cues and knowing she’s not OK without her telling us there is something wrong.”

Through the work of ATS, and its ability to address major issues in the challenges around sustainable discharges, the initiative is understandably attracting attention from beyond the East Midlands.  

Dr Pendeke says the hospital is exploring ways to work with other providers around the country to help replicate the service and its success, to benefit healthcare generally. 

“We are potentially looking at developing a service that mirrors ATS in terms of functionality, one that could look at patients from non-secure environments,” says Dr Pendeke. 

“We want to cater for as wide a group of patients as possible, so no one is left behind in accessing the much needed transitional support. 

“It’s about having conversations with providers from other areas and seeing whether they need this level of support for their patients as they transition from hospital and back into their local area.”