Supporting patient discharges from hospital care into the community

The Assertive Transitions Service (ATS) supports people to transition from secure in-patient mental health care services into the community across Northamptonshire, Leicestershire, Derbyshire, Nottinghamshire and Lincolnshire.

We provide enhanced ward in-reach and integrated community support delivered by two multidisciplinary teams in the north and the south of the East Midlands region. We work with patients, their families, existing care teams and community providers, such as supported-living organisations, to proactively overcome many of the barriers which patients transitioning from secure care face.

“On Wheatfield we have had many very positive experiences of working with ATS and hope to continue to do so in future. I have no doubt that their intervention has enabled us to discharge patients sooner and more safely”. Dave Rodgers, Manager, Wheatfield unit, Northamptonshire Healthcare NHS Foundation Trust

Pre and Post discharge support

The development of the ATS was based around insight from service users and staff who identified a real need for practical pre-discharge support to ensure smooth, successful and sustainable transitions to community living. Support from the ATS has meant that returns to hospital following a patient discharge have been minimal.

Crucial to the design of the ATS is the multidisciplinary skill-mix within the teams, which includes Pathway Navigators, Clinical Team Leaders, Peer Workers and Support Workers from Nottinghamshire Healthcare NHS Foundation Trust and St Andrew’s Healthcare, with specialist support skills from third sector partners Rethink and Framework.

These teams proactively work together with patients and their families and carers up to 12 months prior to discharge and provide tailored help and support during the first weeks and months of independent living.

"Helping to build their confidence and empowering them is really, really important"

Lauren Head is a Mental Health Transition Support Worker in the ATS South Team. She spoke to us about the stigma surrounding a patient's discharge. Interestingly, this stigma is not only seen in the community, from other people and community placements, but from within the patient themselves.

"I would say one of the biggest barriers that our patients face moving back into the community is the stigma, the stigma around mental health. It can be really challenging, and not only the people who are out in the community, the stigma from them, but the stigma that they feel from themselves. They think as soon as they walk out that everybody will look, judge them and see them as their diagnosis when it's not like that. I suppose that's what we're here to do, to support them and reassure them that that's not what people are going do; to look at you and judge you in that way.

Helping to build their confidence and empowering them is really important, because some of the people we work with have been in hospital for so many years, and they don't know what life is like outside in the community. It's about helping them, step by step, to understand what they need to do to lead a successful and happy life out in the community.

The ATS personalise their interventions based on the needs of the patient and their situation. For patients who are struggling to overcome the barrier of what people will think of them in the community, one intervention the team use is a wellbeing book.

"It's got loads of different things in there. Down to daily routine and a lot of strength based work for them to think positively about themselves and move forward. 

We have another intervention called Connected People Intervention because a lot of our patients feel like they're on their own...Connected People Intervention is all about them finding the people closest to them and knowing that they have that support when they're out in the community, it's a massive factor in helping them build confidence, making them feel more secure."

"Hope is the key thing we offer to our patients. It’s the constant optimism, if you like, in the hope of being able to move out of a secured environment and into the community and to be able to live a sustainable life."

Jonathan Clarke is a Rethink Service Manager based in our ATS North Team. Jonathan explained to us the role of Rethink Mental Illness within the ATS and how the ATS works with the patient, clinical and community teams to build upon a person's existing skills to help them overcome the barriers preventing them transitioning into the community.

"We're (Rethink) a holistic service, so we're looking at that wellbeing side of things, as part of the ATS service, and the trust and hope that people have. We're building upon transferable skills that they have and which maybe haven't been as used as much. We're trying to highlight those skills, trying to enable them to adapt to what is a different lifestyle to what they had previously. We're always putting a positive spin on that and trying to make sure that they feel encouraged and strengthened enough to be able to seamlessly transition into the community. So a lot of the interventions we are doing are based around those holistic skills, those people skills and confidence boosting. Then we look at employability, education, housing, benefits, substance misuse and addictive behaviours, things like that.

The ATS service is a link between hospitals and the community but we're very much a complementary service that works alongside the community services, such as community forensic teams and things like that. We’re kind of the good news story, I suppose.

Hope is the key thing we offer to our patients. It’s the constant optimism, if you like, in the hope of being able to move out of a secured environment and into the community and to be able to live a sustainable life."