Mental health pilot helping people leave and stay out of hospital is hailed a success
A pilot mental health community rehabilitation service, launched by Greater Manchester Mental Health NHS Foundation Trust (GMMH) in June 2022, is successfully supporting mental health inpatients to transition back into the community, and stay out of hospital safely.
The Home Engagement and Rehabilitation Team (HEART) was set up with the aim of reducing reliance on mental health inpatient units, by providing community rehabilitation support to mental health service users with complex support needs.
The team provides intensive support to these service users throughout the hospital discharge process and beyond, to help those who would have otherwise struggled to move back into the community.
This could include support in specific areas such as housing, finances, or managing mental or physical health, or more general support to help people live independently, such as budgeting, cooking, establishing a routine, and/or socialising.
The team currently operates in Manchester and Salford, with the aim of rolling out to other areas of Greater Manchester.
Unlike traditional Community Mental Health Teams (CMHTs), the HEART team works with small caseloads through extended working hours, allowing for increased support from early morning to the early evening.
This allows the team - which is made up of senior practitioners, recovery workers, care co-ordinators, occupational therapists and psychology professionals - to offer much more intensive support to individuals based on their needs; to speed up discharges for long-stay patients, and support individuals to work towards their specific rehabilitation goals.
An important part of the HEART model is intensive in-reach work whilst people are on the ward. The aim of this is to build trusting relationships with service users prior to discharge, and ensure continuity of care when they leave the ward – smoothing the transition into the community whilst promoting independence.
From June 2022 to February 2023, 15 service users have been supported by the HEART pilot, with almost 2,500 hours of support being given in total. Six service users have now been successfully discharged from long-term hospital placements, with another four discharges expected within the next quarter.
In addition, the first service user who was discharged with support from HEART has recently taken the next step towards independence by moving on from 24 hour supported accommodation to securing their own private tenancy, where they will continue to receive support from the HEART team.
Nigel Hird, Head of Operations for the Rehabilitation Division at GMMH, said:
“Hospital admission ensures vital, often life-saving care and treatment can be provided for those with acute mental health problems. However, it is important that individuals are discharged as soon as it is safe to do so, to ensure they are given their independence and are able to continue on in the next steps of their recovery journey.
“People with complex health and/or social needs may face challenges preventing discharge, which can mean prolonged hospital stays, which can in turn cause them to become institutionalised - meaning they become even more reliant on such inpatient care and would struggle to live independently in the community. This is not conducive to mental health recovery, and can increase waiting times for hospital beds.
“The HEART team provides intensive support to individuals who face barriers to discharge. We help solve these barriers, which could include anything from housing and finances to physical health concerns or establishing day-to-day routines.
“In the first eight months of our pilot, we have demonstrated that this support, which is tailored to the individual needs of our service users, is effective in supporting people to leave hospital and integrate back into the community safely. This has allowed us to help people, who were previously reliant on mental health inpatient units, to progress, whilst freeing up mental health beds for those who need them.
“Looking to the future, we hope to demonstrate that this intensive support model allows not only for an increase in discharges for individuals with complex needs, but also in a reduction in the rate of readmission longer-term. In time, we hope to roll this support service out to other GM areas, to maximise these benefits for residents.”
Jackie Sichna, Recovery Worker for the HEART team, GMMH said:
“When I visit a service user, I could do anything from going for a walk in the park, to going for a coffee, supporting them with their bills, cooking, helping them to plan their weekly shop, or just listening to them if they want to talk.
“I love working with our service users, making their day better, and helping them to fulfil their potential. If every day I can support someone with something they’re not very confident in, or help them to become a bit more interactive, that is a great achievement.”
One service user, who would like to remain anonymous, has recently passed the milestone of 200 days out of hospital after being a long-stay inpatient for many years. They said:
“I am grateful for all the help I’ve received from the HEART team. It is because of them that I’m staying out of hospital and learning to change my ways. Thank you to everyone.”