Connecting The Dots:

Improving discharge pathways and re-referral rates to community mental health teams in rural settings by connecting service users to local resources

A

Quality Improvement Project in progress with the North Cotswolds community mental health recovery team

Introduction

We choose this project upon realising that a significant number of re-referrals of patients were from rural and often isolated areas. We embarked on this quality improvement project to explore methods to improve the support for these patients which is tailored to their needs and depending on resources available in their area whether that be from established organisations, the voluntary sector or peer support.

Aim

The aim of this project is to explore factors that contribute to the quality and longevity of patient discharge in rural settings from community mental health services. The project intends to explore the needs of community patients which contribute towards:

•Enhanced recovery

•Improved Quality of Discharge

•Reduced service pressures

•Fewer re-referrals to specialist mental health teams following discharge.

1. Literature search to understand initiatives with similar interests.

2.We collated a stakeholder map exploring dynamics of influence, impact and interest in our project.

Lessons Learned

Notably, results showed that 83% of respondents were unemployed, 58% identified access to transport and IT/internet as barriers to wellbeing, while 50% reported meaningful activity would sustain mental wellbeing. These results matched our understanding that rural living with lack of employment/access to transport/digital connectivity drastically impact feelings of isolation and although accounting for a minority segment in reported contributors to sustained recovery, significant affect discharge quality

Measurements

•Referral/re-referral data trends

•Demographic quantitative data

•Service user feedback using survey

•Qualitative Data from stakeholders e.g. GPs, focus groups/interviews

Results

Results showed that 91% of respondents lived rurally and 83% were under continuous care of the recovery team for over 2 years. 91% of respondents felt ongoing support was the most important contributor to mental wellbeing while ‘anxiety’ and ‘lack of confidence’ accounted for 75% of reported barriers to wellbeing

Next Steps

Identified focus areas:

•Patient Environment

3.We created an eight-question digital survey aimed at our caseload of adults aged 18-65 split between rural and suburban locations 9%

•Communication & collaboration

•Standardised discharge

The following changes will be introduced:

•Involve patients and employment worker in discharge MDT

•Standardised discharge letters

•Include IT/transport and employment information in discharge packs

•Continue QI project data collection using focus groups and experts by experience

Summary

•Rural living can be a barrier to meaningful activity and mental wellbeing

•Connecting patients to local resources, transport/employment are power tools in sustaining recovery