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Discharge Pathway Project. Girish Kunigiri Fabida Noushad Mohammed Abbas Colin Gell Sarah Cassie Ayesha Ahmed Terri Eynon. CMHT in Leicestershire. Town Hall Chambers. Melton. Hawthorne. Rutland. Orchard. Market Harborough. Cedars. CMHT challenges in Leicestershire.

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discharge pathway project

Discharge Pathway Project

Girish Kunigiri

Fabida Noushad

Mohammed Abbas

Colin Gell

Sarah Cassie

Ayesha Ahmed

Terri Eynon

cmht in leicestershire
CMHT in Leicestershire

Town Hall Chambers





Market Harborough


cmht challenges in leicestershire
CMHT challenges in Leicestershire
  • Longstanding culture
  • Variation in practices across localities
  • Dependency on psychiatrist
  • Overloaded outpatient clinics
  • Waiting lists for first appointment (average 4-5 weeks; up to 13 weeks)
  • Clinicians struggle when Service User need to be seen urgently
mental health facilitator mhf in leicestershire
Mental Health Facilitator (MHF)in Leicestershire

MHF are mental health professions at Band 5/6/7

Managed in the primary care (along side the IAPT)

Currently in the county (n=18 MHF)


Help GP in assessment and management of SU with SMI (mild to moderate)

Ensure SU on SMI register are followed up and have annual health check

outpatient clinics
Outpatient clinics
  • Consultant case load – 350-600 (largely on their own)
  • Average clinics by one community consultants


  • Junior doctors 2-3 clinics/week

No. of patients seen/week in outpatient clinics

  • 4-5 new
  • About 40-50 follow ups

Discharge range : 35-127 per year per consultant

limitations of clustering exercise
Limitations of clustering exercise
  • Audit done in May 2011- however training of clinicians in clustering completed only by September 2011
aim of discharge pathway project
Aim of discharge pathway project
  • To identify and discharge service users with SMI who have been stable back to primary care
  • To support the primary care in managing such patients
intended benefits of the project
Intended benefits of the project

To make efficient use of resources in secondary care services in managing service users with SMI

To reduce waiting time to see urgent and new referrals in CMHT

Clinicians to be able to provide more active psychological and crisis intervention to their SU

Smooth transition of SU between primary and secondary care

  • Set up a steering group
  • Rolled as a pilot in NWL from Feb 2011-Jan 2012
  • Developed a tool to help identify SU who could be potentially discharged back to GP
    • Those stable for one year or longer with no interventions
    • Advice to primary care included (medication, early signs of relapse, risks and its intervention)
    • Consulted with all the clinicians and GP for their views on the tool
    • Clinician had option of using the tool at discharge or incorporate the content of it in their clinic letter to GPs
methodology cont
Methodology cont…

Educated the CMHT

Educated the GP

Encouraged clinicians to review patients who are stable for discharge

During MDT/CPA meeting


Discussing with patients and carers regarding discharge on their next appointment

methodology cont1
Methodology cont…

Joint decision to discharge to primary care

When necessary involved MHF/GP

Copy of the final care plan/clinic letter given to SU

Fast tract when necessary

Providing advice to primary care

evaluation of the project
Evaluation of the project

Questionnaire sent at 6 months and 12 months post discharge



Questionnaires identified

Care provided in primary care

Increase in workload in primary care

Satisfaction by SU and GP

results evaluation
Results- Evaluation
  • So far responses from 5 GP’s
    • Discharge letter helpful
    • Received help from secondary care when appropriate
    • None of these patients had personalisation and advance directive
    • No additional work
  • Patient responses- still awaited

LPT Clinicians

Reluctant discharging SU

Concerned that SU might not get the right care in primary care

Wary about providing advice to primary care when SU not open to secondary care

Practicality of fast track


Concerned about increase in case load

Expertise in managing when in relapse

challenges cont
Challenges cont…
  • Service Users
    • Concerned that there may be no continuity of care
    • Fear of delay in re-referral/acceptance by secondary care
    • SU choice
    • Issue with benefits
the way forward
The way forward
  • Integrating the discharge pathway project with care pathway development
  • Continue to review existing caseload on a regular basis
  • Openness with SU about reasons for discharge
  • Setting the goals and duration of treatment when SU are first referred to the services
integrating the discharge pathway results with care pathway development
Integrating the discharge pathway results with care pathway development
  • Periodic review of care clusters
    • CPA
    • Change in clinical status
    • Set up maximum time frame
  • Defining possible time frame for each cluster
  • Significant proportion of service users are in secondary care who are relatively stable and could be managed in primary care.
  • Service users should receive the right care at the right time and for right period of time.
  • This pilot has shown that 32 patients were stable enough to be discharged.
  • Service evaluation have shown satisfaction within GP’s. There needs to be a cultural shift with clinicians and service users in bringing this change.
  • Integrating results with care pathway development is the way forward.
  • Christine Green & Sue Scarborough
  • Clinical staff
  • GP’s
  • Service users