We launched a new Assertive Transitions Service (ATS) in February 2020, providing personalised, proactive support to low and medium secure care inpatients up to a year before discharge and then for three months in the community.
This pilot (to March 2021) sees enhanced ward in-reach and integrated community support delivered by two multi-disciplinary teams in the north and the south of the East Midlands region.
The ATS was developed based on insight from service-users and staff which identified a real need for practical, pre-discharge support to ensure smooth, successful and sustainable transitions to community living.
Crucial to the design of the ATS is the multidisciplinary skill-mix within the teams which includes Pathway Navigators, Clinical Team Leaders, Peer Workers and Support Workers, with specialist support skills from third sector partners Rethink and Framework.
These teams proactively work with patients and their families and carers up to 12 months prior to discharge and provide tailored help and support during the first weeks and months of independent living.
The ATS supports IMPACT’s wider aims of improving service-user experience and recovery alongside reducing readmissions, delays in discharge, length of stay and the need for ‘out of area’ placements.