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ACUTE SERVICES
PATHWAY FOR REHABILITATION
Stage 1:
Understanding the Individual (First 72 Hours)
Admission and Assessment
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On admission, service users are welcomed and introduced to the multidisciplinary team. A welcome pack outlining legal rights and advocacy services is provided. An initial care plan and risk assessment are completed in collaboration with the service user. The medical team reviews current medication and liaises with the GP as appropriate. Early engagement includes involving key individuals in the person’s support network and initiating discharge planning to ensure continuity of care from the outset.
Stage 2:
Comprehensive Formulation (First Week)
Assessment and Planning
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This stage focuses on developing a shared understanding of the individual’s mental health needs, strengths, and goals. The first ward round brings together the service user, care team, and key supporters to co-produce a tailored care plan. Reasonable adjustments are made to meet any cultural, physical, or spiritual needs. The emphasis is on shared decision-making and clear goal setting to guide intervention.
Stage 3:
Recovery and Rehabilitation (Weeks 1–4)
Active Treatment and Empowerment
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During this phase, the service user participates in weekly multidisciplinary reviews to monitor progress and refine care plans. A structured program of one-to-one psychological interventions, occupational therapy, and group-based activities supports recovery and skill development. Daily therapeutic engagement promotes self-awareness, resilience, and independence, enabling the service user to take an active role in managing their mental health.
Stage 4:
Transition and Discharge Planning (Weeks 4–8)
Sustained Recovery and Continuity of Care
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The focus shifts to preparing for transition and long-term recovery. The team works collaboratively with the service user to review progress, identify ongoing support needs, and address any barriers to discharge. Strengths-based planning ensures appropriate community or step-down support is in place. Coordination with home teams, families, and carers promotes a safe, sustainable discharge and continuity of care across settings.