Pathway
Aaban’s Young Person’s Pathway comprises a number of phases:
The staff and other young people here are really nice, we all work together- Young person at Moira
Pre-admission
Before a young person is admitted, information will be gathered and considered and if appropriate a face-to-face assessment will be completed with the young person and those that are most involved in their care to assess whether we would be able to meet the young persons needs. We will consider the young persons risks and individual needs in relation to the other young people at the placement, as well as their motivation to engage with their care and treatment. This will be considered by senior management team and a decision to admit shared with the wider team and local authority.
Pre-admission assessment/Matching form/Expectation form
01 - Stabilisation / ‘Settling in’
Information from the young person’s previous placements and their developmental history will inform the initial risk assessment and our four core care plans, as we are getting to know the young person in the early stages of their stay with us. The focus during this period will be on helping the young person to build therapeutic relationships and establish a sense of safety at Aaban. The nursing team will work with the young person to develop ‘My Support Plan’ an initial plan to identify the young persons individual needs so we can start supporting them in a way that is meaningful.
Our therapies and education team will conduct some initial assessments with the young people to help improve our understanding of the young persons needs and future interventions. By the end of the first four weeks we hope to have an initial placement plan in place that will outline the young persons key areas of need and intervention strategies for achieving positive outcomes in line with plans for the young persons discharge.
Risk Assessment / 4 Core Care Plans / My Support Plan / Initial Assessments / Placement Plan / Outcome Measures
02- Developing Understanding / ‘Knowing you better’
Young people will be allocated a named nurse and key worker to oversee care and treatment plans and engage in one to one direct work sessions. Young people will also begin meeting with our team of education and mental health professionals to complete more in depth assessments and develop a collaborative understanding of their needs. A psychological formulation and assessment report will then be shared with the young person, their family and external professionals as appropriate to their future care and treatment. The report will include detailed recommendations about the young persons ongoing needs and discharge plans.
During this phase, young people will also begin standardized interventions that are beneficial to all young people admitted into the service, including attendance at DBT Skills Group, Occupational Therapy and Psycho-education groups and reintroducing young people to learning and education.
PBS Plan (Reviewed monthly) / Psychological Formulation / Written Assessment Report / Individual Therapeutic Programme / Specialist Assessment Tools
03 - Working Towards Shared Goals
‘Exploring feelings & needs’
Young people will have individual psychological therapy to develop a better understanding of themselves and the impact of their past experiences on how they feel, how they respond and what they need from themselves and others in the present.
They will begin active Treatment based on recommendations from the assessment ‘knowing you better’ phase. The staff team will be supported to understand the young persons formulation and will continue to support and reinforce strategies with the young person that have been identified and implemented by the MDT.
We will work collaboratively with the young person and wider system around them to continue to think about individual risk and empower the young person to develop skills in managing their own risks in.
‘Becoming more independent’
Young people will be supported with various aspects of their independence as identified through the ‘Knowing you Better Phase’. Young people will be assessed in the competency skills needed to lead an independent life within the community, at an age appropriate level, from the basic skills of eating and dressing to using/accessing information, hobbies and leisure and managing money. This work will be delivered in both group and individual sessions overseen and led by the Occupational Therapy team but skills will continue to be embedded by the care team. Young peoples independence skills will be regularly re-reviewed with a view to ensuring work is individualised and needs led. As young people progress through their independence they can also be supported to seek further opportunities such as voluntary work or paid employment as appropriate to support re-integration into the local community.
Specialist assessments OT/Bespoke Independence plan.
04 - Transition & Discharge / ‘Moving on’
Discharge planning is considered throughout admission. Prior to discharge the MDT will share recommendations to support the local authority in finding suitable placements that can meet a young person’s needs. We will arrange discharge planning meetings and encourage the young person to be actively involved and updated throughout the process. Once a suitable placement is found a robust transition plan will be created with the young person and new provider/family/carer to ensure seamless transition. To ensure and promote ‘positive goodbyes’ we will offer a ‘check in’ at their new placement when appropriate. A discharge summary is sent to all relevant professionals.
Transition plan/Discharge letter/summary