Referral

Sharon has complex mental health, social and emotional needs impacting her ability to meet her needs [?]. Sharon has been referred to the Devon Partnership Trust (DPT) referral pathway to notify her of the need for s117 planning for her discharge from hospital.

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First contact and assessment

The AMHSC Team and the key worker from the CMHT[?] arrange a joint meeting with Sharon, her IMHA [?] and her ward Multidisciplinary team to start assessments. Discuss Sharon’s experiences, triggers, and current oping mechanisms, her goals, outcomes [?] and what she feels she would want in place.

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Support planning

Together establish goals such as reducing anxiety episodes from daily to once a week. Outline steps Sharon and informal networks can take to manage this. Map out together how additional support services would support to meet Sharon’s needs, goals and outcomes [?].

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Review

Meet with Sharon [after] 6 weeks post discharge with the key worker to review the plan and how the support is working to agree if any changes are required. As there is a change and continued work needed to reduce anxiety episodes a [further?] review is completed at 12 weeks. Although the support has reduced the ongoing support is stable and an annual review activity is requested.