Overview
CAP is a patient centred recovery led service integrating patient's wishes and goals through a Wellness Framework. CAP assists patients in developing the skills and supports to live successfully and satisfied in their community of choice. We exist as a bridge building service to link hospital and community partners in support of our patient's wishes.
CAP is a hospital based intensive discharge planning service and is part of the Regional Specialized Mental Health Program attaching resources and specialities to a patient moving through the Rehabilitation program to effectively coordinate discharge planning and follow up. A deliberate commitment and investment is made with our community partners to ensure effective hospital and community links that operate in the best interest of our shared patients.
Who we are
We are a small, very unique service created to place and support patients returning to the North East Region or wishing to live outside the region. CAP is only a small team of four staff (Coordinator, occupational therapist & 2 peer support workers) that partner with their patients to develop a comprehensive discharge plan and follow up service. We each bring a unique and valued role to the team with shared responsibilities along side the patient.
Who we serve
We serve a population group within the RSMHP who are confronted with severe and persistent Mental Health issues; those experiencing long hospital stays or those who make frequent use of hospital facilities.
What we do
The project was designed to create an ongoing mechanism for a holistic assessment to determine individual service needs and resources that will be required to help that person achieve successful community living.
Our expertise lies in the area of intensive discharge planning and follow up. We partner with our patients to develop a comprehensive assessment profile and wellness plan that can be transferred and integrated with community supports. Our intervention process allows us to assess, plan and evaluate effective treatment regimes that facilitate community capacity and choice towards community integration.
The team (which includes the patient) collaborates extensively with community services and family members prior to developing a community wellness plan. This is facilitated via community meetings and onsite visits. Finally, we follow patients for a period of one year, making on site visits at one, three, six, nine and twelve months, as it is essential to maintain a seamless process offering consultation, support and collaboration with our patient and community partners.
What we have achieved
Outcome measures continue to demonstrate the effectiveness and success of this service. Since CAP's inception in 1998, we have discharged 47 patients, with a 98% success rate, who are living successfully and satisfied in their community of choice.
Strengths
- Full Comprehensive Assessment and Discharge Planning Service
- A flexible resource able to attach to individual patients across the RSMHP
- A seamless service without borders
- Scope and depth of patient served - serving the full spectrum of mental health needs
- Responsiveness of highly skilled staff to patient and community requests
- Integrated life skills training exposure
- Integrated recovery planning and interventions
- Peer Support and peer partnering initiatives
- Capacity building, resource development, community connection, integration and follow up
- Family intervention
- Community support and advocacy
- Face to face follow up consultation with site visits
- Strong, well-established community partnerships coupled with a sound understanding of community interface and politics
- Modeling a truly integrated Partnership approach with a Recovery Focus
- Cost effective team
- Proven outcome measures set against best practice standards
- Quality of life indicators attained with long stay patients now discharged
- Prevention of hospital readmission
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