Item 25

Planning aftercare

Target

a) The CRT discusses and agrees plans for ending CRT care and follow-on care with other involved secondary mental health services before a service user is discharged from the CRT.

b) The CRT makes referrals to health services and other organisations identified to provide support post-discharge wherever additional support is required.

c) A discharge meeting is arranged and service users and involved family are invited to attend.

d) Other involved mental health services attend the discharge meeting.

e) A written discharge plan identifying providers of support following discharge from the CRT is provided to service users.

f) Details of how to access crisis help in the future are provided to the service user and involved family members.

Why this is important

As CRTs are only intended to provide a short-term service to people in crisis it is important that aftercare is planned with all service users. This will allow a continued focus on the person's long-term recovery, and not just on resolving the particular episode of crisis. The CRT can help ensure continuity of care by referring on to other services where necessary and working together with services who are already involved and who will provide ongoing care. Ensuring a smooth handover upon discharge is a key part of this process.

Ways of doing this well 

Discharge planning and meeting

Service users and carers should be aware of the short-term nature of crisis care from the beginning of the period of support.  Plans for ending care should be discussed throughout, and a discharge meeting arranged with plenty of notice to all involved.  Service users and carers feel strongly about how important it is that they know well in advance that care will be ending and have input to this decision.  Other mental health services involved in their care should also be invited to the discharge meeting to ensure continuity of care.  A discharge plan and relapse prevention plan can be extremely helpful to complete collaboratively with the service user and their carer.

Post-discharge contact details

It can be helpful to provide contact details for other local services that service users and carers can access (e.g. support groups, specialist charities etc.). Details of any services the service user might be referred on to should also be given to them.  A clear medication schedule (if not already provided) can be helpful in ensuring the service user feels confident with their medication regime. Details of how to access crisis services again, should they need to, should also be given to the service user on discharge.

Examples of good practice

In our fidelity review survey of 75 crisis teams in 2014, the following teams achieved excellent model fidelity, and can be contacted for advice about how they achieved this:

• West Gwent CRHTT, NHS Wales
• Dudley CRT, Dudley and Walsall Mental Health Partnership NHS Trust
• Barking, Dagenham, Havering HTT, North East London NHS Foundation Trust
• Hastings CRT, Sussex Partnership NHS Foundation Trust
• Wandsworth CHTT, South West London and St George's

Relevant reading