Assessment, treatment through direct and indirect support for autistic individuals who are at risk of hospital admission or placement breakdown.

  • Provide time limited direct/indirect support (not replacing mental health teams) to autistic people/families/services to prevent a family/service breakdown; admission to an inpatient setting; or an out of area placement
  • Support risk assessment and liaison with care commissioners and/or providers with a view to making immediate changes/enhancements to the persons care and support with the aim of reducing the risk of harm/placement breakdown
  • Deliver support across a range of community settings
  • Contribute to Local Emergency Area Protocol’s (LAEP), Care Treatment Review’s (CTR), Dynamic Support Register (DSR) and MHA assessment
  • If appropriate and required, support the identification of appropriate inpatient bed and support the admission and development of hospital discharge plan
  • Undertake collaborative assessments of the individual and their environment, involving them, other services supporting them and people who know them well
  • Provide bespoke training built around the formulation and plans developed to ensure that they are understood and implemented correctly
  • To monitor the effectiveness of any formulations and plans
  • Specialist risk assessments including person centred risk assessments
  • Work closely and effectively with the individual, family/carers, CYPMHS, inpatient services, social care and other agencies
  • Input to Dynamic Support Register meetings which identifies those individuals who may be at risk of placement breakdown or admission and who can access this service.

Providing bespoke training for carers and agencies supporting those individuals

  • Offer expert advice/guidance to those who support the person on a day to day basis – including but not restricted to families, personal assistants, voluntary, community, social care and other healthcare providers
  • Training and support to other services/support networks on evidence-based approaches to supporting autistic people in order to enhance knowledge and skills across services/localities
  • For those individuals who do not have established support circles (carers / agencies) to train, then part of the process for this team may be creating links / contributing to a wider network of decision making around building bespoke supports
  • Advice to commissioners and strategic planners on the design of services and support with the aim of enhancing resilience and creating capable environments which do not rely on restrictive practices to manage behaviour that challenges.

Coordination of transitions from inpatients to other settings

  • Support the Transforming Care Partnership (TCP) agenda and support timely discharges from hospital
  • Provide specialist advice and support in identifying an individual’s care needs to enable the appropriate care provision can be identified
  • Support with legal decision making within legal frames works such as Mental Capacity Act and Mental Health Act
  • Provide local support at times of transitions from inpatient settings or other out of area placements ensuring clinical handovers take consideration of reasonable adjustments and ASC specific needs
  • In-reach into inpatient settings where appropriate to inform discharge planning and ensure prompt and timely safe discharge and prevent readmission.

The intended clinical outcomes will be to keep children and young people in the community with their families and reduce crisis and reduce admissions (to acute hospital or Tier 4 inpatient services).

September update

Several processes and pathway documents are to be developed; the group has considered the adult service specification to see if anything can be developed from there.

October update

A clinical model workshop will be held on 18 November with a view to developing pathways once the overarching clinical modle is established.

A draft referral pathway has been developed and will be reviewed at the November meeting.

A draft discharge pathway has been developed and will be reviewed by the workstream.