Example journey

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.

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.

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 [?].

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.

Process

1. Referral received by AMHSC from DCC Adult Social Care or Devon Partnership Trust (DPT) only, and is triaged. If referral is not appropriate for AMHSC information and advice is given to the referrer.
2. Accepted referral placed on a waiting list and await allocation of AMHSC worker.
3. Allocated AMHSC to make initial contact and arrange a visit, identifying any adjustments required and need for an advocate.
4. A Care Act and s117 aftercare assessment is completed and agreed with person. Identification of carers and referral onwards if appropriate.
5. Signpost to community voluntary services, rehabilitation and goal based support, carers support services.
6. Support plan agreed with person and any services identified to meet individual outcomes arranged (jointly for s117).
7. Practice Quality check completed by manager, meeting identified outcomes to support funding request.
8. Light touch review, for example within 6-12 weeks, or at least annually. Added to review list and reviewed annually if commissioned services remain in place.