We provide specialist inpatient rehabilitative work promoting personal recovery to people with a complex and diverse range of needs
Referral
The service specialises in patients with multiple/lengthy admission to hospital and poor outcomes in terms of sustained community placements with the aim of providing a systematic care pathway. The patient group will be highly symptomatic, have several or severe co-morbid conditions, significant risk histories, and a high proportion will be detained and may present with some ‘challenging behaviours’. The focus is on thorough ongoing assessment, medication, engagement and supporting patients in managing their behaviour and re-engaging with families and communities and the aim is to make progress towards discharging patients back into the community.
The Rehabilitation Service does not have a dedicated community team and there will be an expectation that the community team working with the Patient will continue to do so throughout their admission participating in the CPA process and discharge planning. There is access to Occupational Therapy, SALT, Psychology, Pharmacy, Podiatry, Dietetic services. Physiotherapy, Spiritual support, a Psychiatrist specialising in rehabilitation and social psychiatry, and an experienced nursing team.
PLEASE ENSURE THAT ALL REFERRED PATIENTS ARE AWARE THAT FROM THE 1ST OCTOBER 2016, ALL INPATIENT AREAS, INCLUDING REHABILITATION UNIT, DO NOT PERMIT SMOKING. NICOTINE REPLACEMENT THEAPIES WILL BE AVAILABLE FOR PATIENTS WHO SMOKE
Typical patients will have features such as:
- Treatment resistive schizophrenia.
- Patients with complex needs who are hard to engage and have associated physical health needs which impact upon their mental health.
- Complex co-morbid presentations which impact on their mental health
- Mood disorder – moderate/severe depression, mania/bi-polar.
- Highly problematic behaviour caused by Obsessive Compulsive Disorder
Referral to the Rehabilitation Services may be considered in various circumstances:
- Adults 18 plus years old
- When a patient with major or complex mental health needs, on an acute ward, has become ‘stuck’ and non-progressive in their recovery;
- When a patient is facing a transition from a highly supported setting to a less supported placement;
- this includes patients leaving forensic or secure services,
- patients leaving out-of-area placements,
- or an identified longer term rehabilitating process
- When a patient needs help in overcoming disabilities associated with severe and complex mental health problems that would benefit from ongoing assessment and recovery focussed intervention
Referrals for male only Maple High Dependency Ward (formerly known as Locked Rehab). If referred for the high dependency ward, the following criteria must be met
- Detained under the Mental Health Act (including 2007 amendment and part 3)
- Assessed as presenting a risk to themselves or others
On receipt of the referral, arrangements will be made for a face-to-face assessment of the patient and discussion of the patient with the team currently providing the care. The assessment is normally undertaken by two senior clinicians/AHPs from the Rehabilitation Service.A decision will usually be made at the referrals meeting on the following Monday and the outcome communicated to the consultant psychiatrist. Under exceptional circumstances, it may be possible for the patient to be accepted and transferred before the next referrals meeting.
Referral can be made by any member of the MDT providing the referral has been agreed by the healthcare professionals working with the service user
Surname: / Forename:Preferred Name: / Age:
Date of Birth: / NHS No:
Date of Admission: / Consultant:
Currently an
In-Patient: / Yes No / If yes, state ward:
MHA Status: / Date of Detention (If applicable)
On CPA: / Yes No / CPA Care Co-ordinator
Address: / Next of Kin:
Telephone: / NOK Contact:
Mobile: / Relationship:
Date of most recent OT assessment:
Is the referral for open rehabilitation ward or Maple high dependency? / Open Maple/HD / Interpreter Required:
If yes, state language: / Yes No
Does the Service User have the capacity to consent to admission to Rehabilitation Services? MCA for informal patients re referrals to the Rehabilitation Services must be completed on RIO and a copy attached
Capacity Assessment completed for Referral: Yes No
Copy Attached: Yes No
Is Deprivation of Liberties currently in place for the Service User, if informal?
Yes No N/A (Detained service users only)
Health/Social Care Professionals Involved:
Name / Profession / Address / Telephone No
IMHA/IMCA
- Significant psychiatric history/past events ie service contact history/life events/previous community care:
Diagnosis:
- Current presentation
- Current risks including any safeguarding issues
- Purpose of referral for Rehabilitation work
Please tick as many of the following presenting difficulties as are applicable
Treatment Resistance
Non progressive with their recovery
Medication Concordance
Engagement with Services
Functioning and daily living skills
Motivation
Multiple admissions to acute psychiatric wards
Secondary diagnosis e.g. reduced cognitive function
If the person has been in hospital for over 3 months
Please expand upon any of the sections ticked above.
Please note that a clear rationale for rehabilitation does reduce delays with assessment and decision making.
If referral is for Maple High Dependency Ward please outline the reasons.
- Current accommodation
Residential
Supported Living
NFA
Own accommodation: Owned or rented (please specify)
Other (please specify)
Please outline any accommodation issues and previous levels of support
- What are the Service User’s views about the referral, and their goals and aspirations for the future?
- Are family/carers aware of the referral? What are their views?
- Any other additional information:
- Rehabilitation Service MDT Discussion
Decision to admit
Yes No
Signature and designation:………………………. …………….. Date:…………………
Signature ...... …………………………………………… Date…………………………
(Referrer)
Please send completed referral to
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