Key People

Care Pathways

Admission & Assessment Phase

The admission assessment process is anticipated to be completed within the first 3 months. Service users will be introduced to the concept of shared responsibility for establishing and working towards recovery focussed goals through introduction to the Pathway Journal – a diary based booklet that will enable a service user to predict, plan & reflect upon their recovery pathway.

During the Assessment phase tools such as the Recovery Star & Recovery Skills Assessment, a functional assessment will be completed as will a Psychological Assessment with the aim of developing a formulation that will guide development of meaningful care plans, including the ‘Moving On’ plan which will set out early aims for discharge.

Shared Management Phase

The assessments completed during the initial phase will determine which pathway a service user requires. Pathway 1 is offered as a shorter term, more intensive recovery pathway. Recovery Progress Reviews will be held 3 monthly up to the 1 year marker with the aim of planning discharge within that time frame. Pathway 2, where a longer period of support is predicted as being necessary for maximum rehabilitation, will see Recovery Progress Reviews being held 3 monthly up to the 1 year marker & then 6 monthly review thereafter for a maximum of three years.

During the Shared Management Phase the Pathways team will meet with the service user to develop a list of meaningful goals and objectives for the rehabilitation period; the ‘’Moving On’ plan will be developed in keeping with the shared. The Key worker will meet with the service user weekly, under supervision from the Unit manager or Deputy to plan relevant and meaningful interventions. The keyworker will refer to outside agencies as needed and will liaise with professionals to determine recovery expectations in line with service user goals.

During the shared phase group or individual therapies will be offered as appropriate and readiness for self-management will be assessed in preparation for opportunity for self-management to be offered. Managing medication, independent budgeting, planning of activities, activities of daily living et cetera can all be rehearsed during the shared management phase.

Self-Management

Movement to the Self-Management Phase will be agreed via the Recovery Progress Review meeting once rehabilitation skills have been rehearsed and a period of supported self-management has been successfully undertaken. During this phase, which is predicted to be 3 months in duration, service users will have opportunity to review things needed to achieve the ‘Moving On’ plan and any further skills training such as paying bills, ordering medication, following a relapse plan can be undertaken and individuals can be supported to find & secure new accommodation if needed. Tasks necessary for planning discharge will be identified during a Pre-Discharge Meeting & responsibility for tasks can be shared with Care Co-Ordinator or other named worker.

Once new accommodation is secured keyworkers can provide ‘buddying’ to the new area to prepare for the transition & a local activity plan can be developed. This will again provide opportunity for skills training as needed. Rehabilitation & Relapse Planning will be undertaken by senior staff in this phase of the recovery journey in preparation for discharge. We will encourage service users to use their Pathway Journal to reflect upon their recovery journey & will support the writing of a goodbye letter to aid acknowledgement of the ending of key relationships established during the service users time at Pathways.

Discharge

Discharge meeting – This forum will enable information to be shared and legal frameworks & responsibility to be handed over to the Community team. At this time a telephone follow up or pop-in can be arranged to ease the transition to community. However, any issues that might arise during a follow up will be forwarded to the Community team as Pathways will cease to have responsibility for the service user care at the time of discharge.

Care Path Diagram

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  • Care Quality Commission
  • Investor In People

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