The care pathway includes an agreed way of working and a comprehensive set of policies and procedures from referral to discharge.
Transition period
During the period before admission, there will be contact between the patient, commissioners and the Multi Disciplinary Team (MDT) who will be working closely with them. Staff will work with the patient to ensure they understand their initial care plan, proposed for admission.
Admission
The patient will be initialy orientation to the ward and staff and an explanation of the facilities available will be given to them. If required a DVD in British Sign Language (BSL) will be available, explaining the the service facilities.
Assessment Phase
This is dictated by service specification and includes risk assessments, mental health assessments, life skills and rehabilitation needs. At the end of the assessment period the individual care plan will specify treatment targets for the patient to be discussed at the Care Program Approach (CPA) meeting.
Treatment and Rehabilitation
The treatment and rehabilitation will take place in the hospital environment, this will include learning new skills for independent living, practising old skills, psychological therapies and where identified, offence work and risk management will be undertaken.
Discharge
Planning for discharge begins at admission. Stakeholders and carers will be involved in discussions about discharge from an early stage. Guided by robust risk assessment, discharge to St George Health Care 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. 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 where identified:
- Comprehensive and timely pre-assessment
- Rehabilitation programmes including daily living skills
- A comprehensive 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.
