Discharge planning

S is an autistic man who throughout his childhood and young adulthood experienced bullying and being exploited by others. S was always a bright and intelligent child and would hide his differences. At 16, he went to college to study IT. He changed courses a few times and appeared to struggle with friendships. S met some people who introduced him to drugs, including a drug dealer who took advantage of him. S was a victim of mate crime. S became distressed and his became more physically aggressive towards family and himself. 

The police were called multiple times, he became homeless, and he had a number of referrals for health and social care assessments. The outcome of these was that S was not eligible for social care support, at that time. He was subsequently detained under the Mental Health Act at a local hospital for 6 months, during which time he was diagnosed with psychosis, and experienced various ward moves. He was discharged into a supported housing scheme for people with mental health needs. There was minimal support and he started using drugs again. He neglected his personal care and environment and after being in this accommodation for 6 months, he was detained in hospital under the Mental Health Act, again. 

He was in hospital locally for a year, during which time he was diagnosed as autistic. Due to COVID-19 in wards, he was then moved to an out-of-county hospital, where he remained there for another year and a month. During his time in hospital staff became keen to support him find suitable accommodation with support, so that he could be discharged from hospital, and realised that following his previous experience of supported housing more consideration should be given to what would work for this young man. 

Due to the diagnosis of autism, S was identified as someone requiring additional support for his discharge. He was allocated a Transforming Care Assessor and a Life Plan and Community Treatment Review started.

During this process S and his family identified their goals. The hospital and multi-disciplinary team guided by these goals then created a pen picture about S for support and accommodation. The pen picture then helped discussions with different providers about whether they could support S. A shared flat became available, with one other person already living there. The flatmate matched well with hobbies and what they both liked to do, they were both of a similar age and liked the idea of having a flatmate. We introduced them to each other, and they decided to live together. S used some section 17 leave to meet some more with his proposed flatmate and to see the flat.

Section 117 planning and discharge meetings were held between the community and hospital teams. Both health and social care worked jointly throughout the discharge to ensure the s117 plan was comprehensive. This included the overseeing, monitoring and reduction of medications, community mental health support, formal care provision and accommodation. They took a person-centred approach and S and his flatmate jointly helped pick out colours, designs, and uses for spaces in their flat.

The provider also met with S and his flatmate to help them create a care plan and understand S’s wishes for his support, alongside the requirements of the support.

Despite any worries, S’s move went without any issue. He settled in well, got to know staff and his flatmate and has been there for over seven months without concern. He sees family at least weekly, is exploring college options and goes out daily with staff. He is helping with other people’s pets at the house and is hoping to get some guinea pigs of his own. 

He and his flatmate continue to be friends and have said they would like to continue living together. They do a range of activities together and apart.

S’s next goal is to build his confidence up to spend time in his local community doing ordinary things – like shopping - without staff. The provider is working with S to shape the care and support over time. And the multi-disciplinary team are keeping the arrangements under review, having regular review meetings to check that everything is still working well.

The provider finds it helpful to be able to discuss changes or new issues with the multi-disciplinary team and welcome the constructive dialogue, with S and his flatmate also involved in finding solutions.

The close attention to matching S with a potential flatmate has paid dividends. It was also important that S was invited to make the decision about whether to live with this flatmate. He was offered a choice and made a positive decision.

There was also parity of esteem among professionals as equals, across health and social care, across commissioners and operational colleagues, and across commissioners and the provider. They took a person-centred approach, keeping S and his flatmate involved in decision making.

It was important to agree, early on, the conditions for success. There was some debate in the early stages about who was the lead commissioner. There was clear agreement to work together as equals, rather than in a hierarchy, so no partner is seen as the lead.