Care Pathway
The care pathway includes an agreed way of working and a comprehensive set of policies and procedures from referral to discharge.
Transition period
It is expected that during the period before admission, there will be contact between the patient/Commissioners and MDT who will be working close with them, patients will be encouraged to visit the service. Staff will work with the patient to ensure that they understand their initial care plan, proposed for admission. If additional work is needed, in the interim this will need to be costed separately.
Admission
On admission the patient should be familiar with their named nurse/key worker. There will be an initial orientation an explanation of services. A DVD in British Sign Language (BSL) will be available, explaining the service.
Assessment Phase
This is usually for a period of 3 months and includes risk assessments, mental health assessments, life skills and rehabilitation needs. All ABI patients have neuropsychological assessment including cognitive assessments, need for psychological treatment, including offence work, some Care assessments in the community are considered.
It is recognised that many service users may have established institutionalised behaviour and will have had limited opportunity for community integration, in the past. Part of the assessment involves opportunities to experience new activities and make choices for the future. At the end of the assessment period the individual care plan will specify treatment targets for the patient to be discussed at the CPA meeting.
Treatment and Rehabilitation
This may take place in the hospital or within a St George Healthcare Group community placement. This will include learning new skills for independent living, practising old skills, psychological therapies, offence work, and risk management.
Discharge and Community Accommodation
Planning for discharge begins at admission. According to the principles of least restrictive practice, stakeholders and carers will be involved in discussions about discharge from an early stage. Staff is aware that many patients with cognitive impairment require lifelong support and supervision and structure in order to function and be safe. However, this need not be in a hospital environment. Guided by robust risk assessment, discharge to St George Healthcare Group community placement may allow an improved quality of life whilst maintaining the same cognitive rehabilitation approach to care, access to the MDT and proper supervision. In effect this is likely to mean that some patients, previously unable to leave a hospital setting, will be able to live in the community, with individual support. The needs of Deaf people will be considered in keeping with their special cultural and linguistic needs in addition to all the principles outlined above.
The unique Care Pathway will provide:
- Comprehensive and timely pre-assessment
- Rehabilitation programmes including daily living skills
- A range of therapeutic programmes
- Step down to least restrictive environments
- Robust risk management plans
- Plans for supported community living
- A multi disciplinary team approach to rehabilitation is adopted with social inclusion as the ultimate goal.
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