“Rehabbable” or not
In the second of their regular joint blogs, Strategic Lead for Complex Care Clair Jones and CRAC Team Consultant Psychiatrist Dr Ian Davidson focus on the theme of rehabilitation.
“They aren’t suitable for rehabilitation.” Too often this was a traditional gatekeeping response for people who needed more than standard acute care.
Part of the issue is terminology. The dictionary definition of Rehabilitation is the process of restoring function and abilities which have been lost. Habilitation is the process of gaining functions and abilities for the first time.
The Joint Commissioning Panel for Mental Health (www.jcpmh.info, October 2016) defines mental health rehabilitation as “the whole systems approach to recovery from mental illness that maximises an individual’s quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and leads to successful community living through appropriate support.” It then further modifies this by including that this is for people “whose complex needs cannot be met by general adult health services.” It is therefore much more than rehabilitation and habilitation in the general dictionary sense and should be part of the work of any level of mental health services.
This makes it an oxymoron for specialist mental health services to reject someone on the basis that they are unsuitable for specialist rehabilitation as either certain skills or functions can’t be regained or learned for the first time for whatever reason. The key focus of specialist rehabilitation should be on those whose needs can’t be met by general adult health services. This means that they should take such people and focus on maintaining their best level of functioning whilst working to put together a successful community support plan for community living. Specialist inpatient rehabilitation should be for those who can’t otherwise be discharged to appropriate supported community living.
An important distinction in specialist inpatient rehabilitation units is whether security is the main issue, in which case the person should be in a secure unit (Low, Medium or High security as determined by Forensic Mental Health services and NHS England) or don’t need secure, in which case they will be in a non-secure inpatient unit. These will then vary according to level of intensity e.g. high dependency. “Locked rehabilitation” has no useful meaning and isn’t supported by the guidance. Rehabilitation units are either secure or non-secure. Any mental health inpatient unit can take people detained under Mental Health Act and so must be able to detain those who should be detained, but for non-secure units the ability to lock doors should not be a defining characteristic.
The key function of a non-secure inpatient rehabilitation unit is to expedite the person back to community living with appropriate support as quickly as possible, not to lock them up. This includes person centred care and identifying with them what further improvement can realistically be achieved in hospital and what community support is most likely to help them maintain their best quality of life, without adversely impacting on the quality of life of others.
So “they aren’t suitable for rehabilitation” tells you more about the mind-set of the person/service saying it, than the person they are talking about. If the person can be successfully supported in the community then they don’t require inpatient rehabilitation, but if they are in a non-secure hospital bed beyond the acute phase then they do need rehabilitation. Whether this rehabilitation needs to be in hospital or in the community depends on the assessment of the individual: their strengths, needs and aspirations and what types of support package can be made available in the community by all relevant agencies.
The CRAC team within CWP has recently taken on the inpatient rehabilitation gate keeping function to align with the rehabilitation in reach to acute wards and care coordinating all those in tertiary complex beds. This includes the specialist rehabilitation beds provided by CWP who take those people with the most complex needs to keep them closest to home. The function of gate keeping is to ensure that people either get the necessary recommendations for successful support in the community, or if not yet ready for that step, rapidly moved to and through tertiary complex care to get them to that stage. We consider that anyone with over 40 days acute inpatient care is in need of some form of rehabilitation approach, preferably community based. However, if they need an ongoing hospital admission then they should be in the best bed for needs, in the least restrictive setting, closest to home and they should be actively care co-ordinated to ensure discharge at the earliest opportunity.