Discharge Planning And Aftercare at Bromley Road Hospital

At Bromley Road, a vital part of a service user’s recovery journey is discharge planning. It is a vital component in planning for the future and aftercare follow ups play a huge part in the process. 83% of discharges this year have resulted in service users moving out of the hospital into either their own home or residential care.

D has been an in-patient at Bromley Road Hospital for approximately 12 months. He was admitted from an NHS acute ward after several short admissions.

During his time at Bromley Road, D developed improved insight into his mental illness after having engaged in an individualised psychology programme developed by the lead psychologist.

D has made steady progress and some very positive changes at Bromley Road. For the first time whilst in an in-patient setting, D developed many friendships on the ward and developed therapeutic relationships with staff.

D is now utilising four weeks section 17 trial leave to his flat in the community with the hope that following the four weeks, he can be discharged on a Community Treatment Order (CTO). There is a support package in place and this was organised in partnership with his therapy team at Bromley Road and the local Community Mental Health Team (CMHT). This plan has been put in place to monitor compliance with medication, mental state and his overall wellbeing.

As part of D’s discharge planning, an agreement was made with D that the ward manager would call him every week to check-in and to ensure that his leave was going well. This provides staff and D with the opportunity to assess how well his leave is going and for D to express any concerns or worries that he may have. It is also a good opportunity for D to tell us what he has been doing with his time, how he is engaging with his care package and to let us know what is going well.

When asked about his journey, D said:

“I miss the staff and friends I made at Bromley Road but I know this is normal and I’m glad staff still call me. I’m compliant with all my medication and I’ve been doing online shopping and even sticking to my weekly budget. I’ve been getting on well with my family and went to my nephew’s birthday party. I was really happy to be able to buy him a birthday present. I’ve reconnected with old friends from school and I’ve started going to the gym. My Support Worker comes to see me in the evenings for 15 minutes and I have longer visits twice a week. Moving home has been the best thing that has happened to me in a very long time.”

D’s discharge date is now confirmed and he has agreed for the Ward Manager to call him for the rest of the year on a fortnightly basis.

Aftercare is usually provided as section 117 aftercare by the service user’s Care Co-ordinator. However, at Bromley Road, the staff go above and beyond in ensuring that the service users’ time at Bromley Road is not wasted. It is important to us that discharged service users are supported to maintain their mental health and wellbeing by remembering all the skills learnt previously to ensure that they can remain independent and out of hospital. The result is a positive discharge and avoidance of re-admissions.