Exploring service users’ experience of transition from inpatient rehabilitation to community settings
Intended for healthcare professionals
Evidence and practice    

Exploring service users’ experience of transition from inpatient rehabilitation to community settings

Christina Shearn Trainee clinical psychologist, School of Psychology and Vision Sciences, University of Leicester, Leicester, England
Kelly Fenton Consultant clinical psychologist, Leicestershire Partnership NHS Trust, Leicester, England
Craig Griffiths Clinical psychologist, Leicestershire Partnership NHS Trust, Leicester, England

Why you should read this article:
  • To appreciate the importance of effective management of service users’ discharge from inpatient settings

  • To understand the factors that can enhance service users’ experience of transition from inpatient rehabilitation settings to the community

  • To learn about what elements of the discharge process could be improved to enhance service users’ experience

Discharge from inpatient rehabilitation settings can be a stressful experience for service users and mismanagement of the transition process can have negative outcomes, such as early readmission. This service evaluation explored the experience of people transitioning from inpatient rehabilitation settings to the community to identify what works well in the rehabilitation pathway discharge process and areas for improvement. Eight service users participated. All eight completed a bespoke questionnaire, six of whom took part in a subsequent semi-structured interview. Findings suggest that, overall, participants had a positive experience of transition, particularly in relation to practical and emotional support from inpatient and community rehabilitation services. Areas identified for improvement include increased involvement of family and carers during the discharge process and greater clarity about the role of the various professionals and teams involved in service users’ care once they are discharged to the community.

Mental Health Practice. doi: 10.7748/mhp.2024.e1684

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

cs838@leicester.ac.uk

Conflict of interest

None declared

Shearn C, Fenton K, Griffiths C (2024) Exploring service users’ experience of transition from inpatient rehabilitation to community settings. Mental Health Practice. doi: 10.7748/mhp.2024.e1684

Published online: 23 January 2024

Background

The provision of mental health support in the community offers service users more flexible options with regard to their care and recovery than inpatient services, and minimises the risk of institutionalisation (Chow and Priebe 2013). Furthermore, evidence suggests that many service users prefer to live as independently as possible in the community rather than receive support in hospital (Richter and Hoffmann 2017). However, some people, for example those with severe and enduring mental illness, such as psychosis or schizoaffective disorder, may require a period of inpatient mental healthcare before discharge to community services.

For some service users the transition from inpatient settings to the community can be stressful and chaotic and can adversely affect their psychological well-being (Wright et al 2016). Additionally, discharge from inpatient services has been shown to be associated with the development of anxiety, including in service users for whom anxiety was not part of their primary diagnosis (Owen-Smith et al 2014). Anxiety in this context may be due to a fear that professional support will be reduced following discharge (National Institute for Health and Care Excellence (NICE) 2016) or concerns about social reintegration into the community (Nolan et al 2011). Furthermore, as well as managing the symptoms of their mental health condition, service users frequently experience functional challenges, such as managing everyday activities, which can complicate their recovery and transition to the community (Dalton-Locke et al 2021).

If transition is not managed effectively, service users may experience distress and early readmission (NICE 2016). More concerning is that the risk of suicide has been found to be particularly high for service users in the first two weeks following discharge from inpatient services (Meehan et al 2006). It is vital, therefore, that inpatient and community mental health services collaborate closely during service users’ transition and provide timely follow-up post-discharge (Meehan et al 2006).

NICE (2016) recommends services adhere to the following overarching principles to support effective transition:

  • Ensure the aim of care and support of people in transition is person centred and focused on recovery.

  • Work with people as active partners in their own care and transition planning.

  • Support people in transition in the least restrictive setting available.

  • Record the needs and wishes of the person at each stage of transition planning and review.

  • Identify the person’s support networks. Work with the person to explore ways in which the people who support them can be involved throughout.

Transition should also be suitably paced so that the person does not experience discharge as a sudden event and should include periods of phased leave (NICE 2016). Importantly, rehabilitation services should provide support across inpatient and community settings to enable service users to gain independence gradually (NICE 2020).

Service evaluation project

Leicestershire Partnership NHS Trust, which provides community and mental health services, has two inpatient rehabilitation units for people with severe and enduring mental illness, some of whom are detained under the Mental Health Act 1983. The two inpatient rehabilitation units have 30 mixed beds and eight high-dependency beds. Rehabilitation interventions are delivered to service users by a multidisciplinary team comprising nursing and medical staff, occupational therapists, psychologists, speech and language therapists and physiotherapists. For those detained under the Act, rehabilitation interventions include planned leave from the unit as part of their support for recovery and transition to discharge.

In 2020, the trust created a community enhanced rehabilitation team (CERT) in response to the coronavirus disease 2019 (COVID-19) pandemic, which had resulted in quicker discharge of service users from inpatient units (Kidd and Fenton 2022). The CERT is a psychology-led service comprising clinical psychologists, nurses, healthcare support workers, psychiatrists and occupational therapists and offers transitional support to service users during the discharge process, with the aim of reducing their anxiety, preventing early readmission and supporting their wider support network, such as family and friends (Fenton et al 2021). The CERT now forms part of the trust’s rehabilitation pathway (Kidd and Fenton 2022).

The authors of this article, who work across inpatient rehabilitation teams and CERT, formed a project group to undertake a service evaluation of part of the trust’s rehabilitation pathway discharge process.

Key points

  • Rehabilitation services should provide support across inpatient and community settings to enable service users to gain independence gradually

  • Inpatient rehabilitation services should involve the service user’s wider support network, such as family and friends, at an early stage in the discharge process

  • Community teams should engage with service users while they are still in the inpatient setting to start to develop trusting relationships that can continue after discharge

Aim

To explore service users’ experience of transitioning from inpatient rehabilitation to the community, to identify what is working well in the trust’s rehabilitation pathway discharge process and to identify areas for improvement to enhance the experience.

Method

Data collection

The service evaluation took place from May-July 2022. Data were collected using qualitative and quantitative methods in the form of a brief, bespoke questionnaire followed by a semi-structured interview. The questionnaire comprised five questions with a Likert-type scale (ranging from 1 = ‘not at all’ to 5 = ‘very much’). The questions were quality reviewed by two members of the project team (the second and third authors, KF and CG) and checked for clarity by two service users, who did not participate in the service evaluation.

The interview schedule was designed collaboratively by the project team. Service users on the inpatient units who were not participating in the service evaluation provided feedback on a draft interview schedule; amendments were made based on this feedback.

Participants

All service users who were transitioning from the trust’s two inpatient units to the community over a three-month period (May-July 2022) were invited to participate. These service users were identified by clinical psychologists who work across both inpatient units, and who informed the project team about proposed discharge dates.

Potential participants were approached, either in person on the ward, or by telephone if they were on planned leave, by the first author (CS) one to two weeks before their transition, to inform them about the service evaluation and invite them to participate. Of the 12 service users who were approached, eight agreed to participate. Participants were given a choice of completing the questionnaire and taking part in an interview or completing the questionnaire only. Of the eight participants, six agreed to take part in an interview following completion of the questionnaire.

One to two weeks following their discharge each participant was contacted by the interviewer (CS) at a pre-arranged time, either in their home or via telephone depending on their preference, and asked to complete the questionnaire then take part in the interview, where applicable. For participants who had requested a telephone call, the interviewer asked the questions and transcribed the person’s responses. Those who met with the interviewer in person completed the questionnaire themselves before the interview. For non-English speaking participants, the questionnaire and interview were undertaken by telephone supported by the trust’s on-demand interpreting service. All interviews were audio-recorded and transcribed by CS.

Data analysis

Quantitative data obtained from the questionnaire were analysed using descriptive statistics. Qualitative data from the interview transcripts were analysed by the project team using Braun and Clarke’s (2006) framework.

Ethical considerations

As this project was a service evaluation, ethical approval was not required. However, approval to undertake the project was given by the trust’s quality improvement programme in March 2022.

Participants were provided with a participant information sheet detailing the service evaluation project and were asked to sign a consent form, which stated that the findings might be published in a peer review journal. Identifiable data were removed from transcriptions of audio-recordings and recordings were deleted following transcription. Data were stored on secure NHS computers.

Findings

Demographic data were collected from participants’ electronic patient records with their consent. Participants’ characteristics are presented in Table 1.

Table 1.

Participant characteristics (n=8)

Characteristic
Age (years)Range 26-64
Mean (SD*) 43 (13)
Gendern (%)
Male
Female
6 (75%)
2 (25%)
Ethnicity
White British
Asian or British Asian – Indian
Asian or British Asian – Pakistani
4 (50%)
2 (25%)
2 (25%)
First language
English
Urdu
Gujarati
5 (63%)
2 (25%)
1 (13%)

*SD=standard deviation

Questionnaire

Participants’ responses to the questionnaire are shown in Figure 1. When asked how satisfied they were with their experience of discharge, seven (88%) participants answered ‘very much’. Most participants rated the extent of help from inpatient services, their involvement in their own discharge planning and the provision of information about discharge as ‘very much’ or ‘moderately’. The extent to which inpatient staff attempted to involve family and/or friends in discharge was the lowest rated item, although half the participants selected ‘very much’.

Figure 1.

Participants’ responses to the questionnaire

mhp.2024.e1684_0001.jpg

Interviews

Three main themes were identified through thematic analysis of the interview data: requirements for successful discharge; challenges of discharge; and hope for the future. The first two themes contained subthemes. The themes and subthemes are discussed below and illustrated by participant quotes.

Requirements for successful discharge

This theme contained three subthemes, practical support, emotional support and feeling prepared for discharge.

Practical support

Several participants described different types of practical support that were offered to them by the inpatient rehabilitation team and CERT, including opportunities to practise daily living skills before discharge:

‘A good positive was that I was learning how to cook and as soon as I left, I could look at a recipe and cook anything, so that was good.’ (Participant 6)

Other types of practical support provided before, during and after discharge included information on housing, GP registration, medicine arrangements and transport. Participants also described being offered ad hoc practical support by the CERT when they experienced challenges in the build up to discharge, which provided a sense of relief:

‘It was getting the bills sorted that was a challenge… I set up a direct debit and it didn’t work… in the end [the community support worker] did it and it worked straight away.’ (Participant 1)

Practical challenges that adversely affected the discharge process included having no social care package in place, difficulties in obtaining a translator, delays in medicine availability and an inability to find suitable housing:

‘During my ward rounds… they would ask me “How’s it going with the housing?” I’m still struggling here, nothing’s coming up… It was the fact that all of us there in that room couldn’t make one of the properties appear.’ (Participant 6)

Emotional support

Participants described how inpatient rehabilitation staff provided them with a positive outlook and encouragement during the discharge process and that they felt reassured that they could contact the inpatient unit if they needed help following discharge:

‘[The inpatient discharge team said] always to have a positive thinking outlook and if there’s any problems then to let them know, but I’m always happy.’ (Participant 3)

One participant also discussed how receiving support from a psychologist before discharge, with regards to discussing and planning ways of adjusting to the community, had been beneficial. Similarly, meeting members of the CERT before discharge was regarded by participants as important, and one expressed how they valued having regular communication and already being familiar with their community team while adjusting to their new setting:

‘The [CERT] team were talking to me before I left… Those introductions are what make it so normal when you are discharged. Now you’re in a different environment, but you still see them… Kind of like grounding… It’s like you just stepped out of your own room into a different room, and they’ve walked along with you there.’ (Participant 6)

The involvement of family members in the discharge process was identified by some participants as a source of emotional support. While most participants were satisfied with the level of family involvement, some would have preferred more input from and easier access to the inpatient rehabilitation service for their wider family and friends:

‘They told [my sister] stuff… My sister’s my next of kin but she doesn’t understand things, so my uncle and auntie’s the next step but they couldn’t get through to the office.’ (Participant 1)

Feeling prepared for discharge

Several participants said they felt ready for discharge and that it had come at the appropriate time in their recovery:

‘I am fully satisfied with the experience in hospital and the discharge process. I was expecting that when I get care from them, I get better, which is truly what happened… I am feeling better, I am happy to go.’ (Participant 4)

Most participants mentioned having meetings and discussions with inpatient staff regarding the discharge process and felt involved in the decisions made:

‘I was told everything – that I would be going to the community centre and when the nurses come to let them because they would come to do the injections… It was good because they explained everything to me.’ (Participant 3)

However, one participant, who was discharged to residential accommodation, said they had wanted more choice in the process and would have preferred to have been discharged home directly.

Most participants commented that inpatient staff organised a gradual increase in the time they spent in the community in preparation for discharge and regularly reviewed this with them:

‘They just tried to get me to go to my flat on my own, do the bus route… They asked me how it went, I said “it went really well”, so they got some more leave prepared. I seemed happy with it and the next thing I was on a week’s leave… they gave me a couple of phone calls each day to make sure I was okay.’ (Participant 1)

Challenges of discharge

This theme contained two subthemes, organisation, clarity of information and navigating multiple teams and services and community reintegration.

Organisation, clarity of information and navigating multiple teams and services

One participant described how the pace of discharge changed and that they experienced alterations to their discharge plan:

‘In terms of the pace of things, initially they said three months and now they’re telling me I’ll be staying in this place for six weeks and then I’ll be able to go home… it was really fast paced for the first three months and then it sort of slowed down.’ (Participant 5)

While most participants were generally happy with the pace of discharge, some felt that it was rushed and required a lot of organising:

‘In the end, everyone was rushing around, but I had my luggage packed, I was waiting to go. I was gonna get a lift at first, but I had to organise a taxi in the end [laughs] and I had to get the money ready… I had to go at tea-time, medication time, crikey [laughs]. It’s my fault for booking it for four [laughs].’ (Participant 1)

Another participant expressed confusion about the various teams involved in their discharge. The participant explained how they were unclear about what discipline, team or service the staff they interacted with belonged to and the purpose of their roles; for example, they had thought that one of the mental health nurses was a psychologist and were unsure who worked in health services and who worked in social care services.

Community reintegration

Some participants experienced feelings of discomfort in relation to transitioning back to the community, for example apprehension about interactions with neighbours following extended periods of absence:

‘It felt strange going out on my own because the neighbours hadn’t seen me for ages, but they’ve been supportive. It felt weird going into Co-op [laughs], they said “I haven’t seen you for ages” and I’ve gone “Oh God” [laughs].’ (Participant 1)

One participant reflected on the difficulty of returning to an environment in which they had previously been very unwell and discussed experiencing an initial increase in their mental health issues on returning home:

‘When I was living here… I would hear voices every day, especially at night… It’s kind of like a cycle because it’s something to do with the environment and that idea was gotten across to me that it could be my problem. Like it could be the history in the house, the fact that I’ve got no end of history in my head… I thought I was not dealing well with that, but it has changed quite a bit now because of where I’m at with my illness.’ (Participant 6)

Hope for the future

Positivity about the prospect of discharge to the community was apparent in all participants’ interviews:

‘They said “you’ll be discharged today now”, so that was music to my ears [laughs].’ (Participant 1)

Participants described various benefits of being back in the community, including more time spent outside, engaging in hobbies, having more choice of food and spending time with family and friends:

‘I was very happy because I would be able to cook my own food, go shopping, get my own stuff… I’m happy I can eat what I want now here… I can have different types of food and chapati, whereas when I was at the hospital, I was getting potatoes.’ (Participant 3)

Some participants described continued support from CERT, for example through the organisation of well-being or social activities:

‘It is helping in just getting me involved with groups. They gave me letters and leaflets of groups I can get into, like gardening and sewing. That’s what [staff member] is following up now.’ (Participant 1)

Discussion

This service evaluation aimed to identify areas of the rehabilitation pathway discharge process that are working well and those that require some improvement. Overall, the findings suggest that participants were satisfied with their experience, felt involved in and well informed about the discharge process and felt supported throughout transition by the inpatient rehabilitation service and CERT. However, there was variation in participants’ experience of the involvement of family and friends in the discharge process and for some participants there was a lack of clarity about the role of various professionals and services.

Areas that are working well

Practical and emotional support

The findings suggest that the practical support offered to participants before discharge, such as information on housing and opportunities to practise daily living skills, supported effective transition. Additionally, participants felt reassured by continuation of this practical support in the community on an ad hoc basis. This supports NICE (2020) recommendations that programmes to engage people in ‘community activities’ should be flexible and accommodate individuals’ needs.

Some participants named occasions where practical issues, such as having no social care package in place or an inability to find suitable housing, adversely affected the discharge process. These types of issues have been shown to delay discharge from inpatient settings (Poole et al 2014).

In a study of service users’ (n=10) experiences of the discharge process and following discharge, participants described transition to the community as a particularly emotional time (Owen-Smith et al 2014). Some participants in the present service evaluation expressed an initial sense of unease on re-engaging with people in their communities and returning to environments where they had previously experienced mental health difficulties. This unease may reflect a fear of stigma and judgement from the community regarding mental health issues following a period of inpatient admission (Manuel et al 2012, Redding et al 2017). However, participants also described how inpatient and CERT staff provided them with emotional support through, for example, displaying positive and reassuring attitudes and providing pre-discharge psychological support to help them adjust to returning to the community.

Additionally, being familiar with community team members before discharge contributed a feeling of being ‘grounded’ in their new environment. This supports Owen-Smith et al’s (2014) conclusion that it is important for service users to maintain relationships with known service providers where possible during the discharge process to support effective transition.

Preparation for discharge and integration in the community

Dissatisfaction with discharge timing and a sense of feeling unable to cope in the community following a period of inpatient admission have been found to be associated with service user distress and readmission (Duhig et al 2017). Participants in the present service evaluation felt their discharge came at the right point in their recovery and that gradually increasing the time spent in the community had helped them to prepare for discharge. This supports the NICE (2016) recommendation that service users should be offered trial periods outside of hospital before discharge.

Participants also felt well-informed about and involved in the discharge process, which helped prepare them for discharge. However, one participant expressed a desire for greater agency over choice of where to live when discharged. This is an important finding, as service users’ voices are often lost at important points of transition (Wright et al 2016). Rehabilitation services should ensure that service users’ views and choices are listened to and accommodated as much as possible throughout the discharge process.

In a systematic literature review, Mutschler et al (2019) found that service users required supported autonomy, safety and reintegration activities to successfully transition from inpatient to community settings, and that unsuccessful transitions were related to inadequate transitional interventions and inadequate social support. In the present service evaluation, participants reported that they were supported by CERT to re-engage in old hobbies, or take up new ones, and to access well-being and social groups and independent activities, which contributed to feelings of pleasure about returning to their community. This finding is important as evidence suggests that although engaging in meaningful activities can provide service users with a sense of routine and ‘normalcy’ following discharge from inpatient services, a lack of confidence and experiencing mental health issues can prevent them from arranging these independently (Nolan et al 2011, Heron et al 2012). Participants in this service evaluation also described how returning to the community provided them with a sense of increased autonomy and choice, which aligns with one of the aims of the CERT, which is to foster independence in service users.

Areas for improvement

Most participants believed that their family members had been involved in the discharge process, which supports NICE (2016) recommendations on the involvement of family in discharge planning and preparation. However, some participants felt that before and during preparation for discharge, inpatient teams could have facilitated more input from and improved communication with their wider family members and friends.

Some participants were unclear about the role of the various professionals and services involved in their care once they were discharged, while others found alterations to discharge plans and disorganised transition processes stressful.

Based on these findings, the main recommendations for practice are:

  • Inpatient rehabilitation services should involve the service user’s wider support network, such as family and friends, at an earlier stage in the discharge process.

  • The role of each of the professionals, teams and services involved in the person’s care should be clearly explained before discharge.

  • Community teams should engage with service users while they are still in the inpatient setting to start to develop trusting relationships that can continue on discharge.

  • Creating opportunities for co-production within inpatient rehabilitation pathways, in terms of planning for discharge from the point of admission, could support continuous, collaborative service review and improvement.

Limitations

One limitation of this service evaluation was the use of a convenience sample, since one third of those discharged to the community during the evaluation period declined to participate, meaning differing views of the transition process may not have been captured. Additionally, those who had positive experiences may have been more likely to agree to participate, which could result in bias. However, the participants did report challenges and gave constructive feedback regarding transition, enabling identification of areas for service improvement. Furthermore, the evaluation included perspectives and experiences from a diverse range of service users in terms of ethnicity and first language spoken.

Conclusion

This service evaluation explored service users’ experiences of transition from inpatient to community settings. Findings suggest that, overall, participants’ experiences were positive, particularly in terms of the practical and emotional support they received before, during and after discharge. Some participants felt that more involvement of their family members would be beneficial, while others were unclear about the roles of the different professionals and services involved in their care once they had transitioned to the community. These are areas that the trust’s rehabilitation pathway discharge services are working to improve.

References

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