Improving Discharge Medicine Service at CPFT: A Comprehensive Overview
Explore the CPFT's efforts to enhance their Discharge Medicine Service through targeted referrals, specific medication instructions, risk management strategies, and future plans for embedding DMS into practice seamlessly. Discover how they cater to different patient needs and ensure a smooth transition post-discharge.
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CPFT joining the Discharge Medicine Service
Child & Adolescent MH Direct admission via mental health act detention Croft Darwin Centre for Young People Phoenix Centre Crisis & Home Treatment Team Crisis Resolution and Home Treatment Team (CRHTT) Adult and Specialist MH Mulberry 1,2,3 Springbank S3 George MacKenzie House Oak 1,2,3,4 Poplar Hollies Waiting list admission Home (self / informal care) Community Team Home (formal care) Acute hospital Out of area service First Response Service Older People MH Denbigh Willow Maple 1,2 Support from outside agency Acute hospital transfer Adult & Older People Rehab Units Brookfields Hospital / CRU Princess of Wales Hospital Trafford Centre Intermediate Care Centre Out of area transfer Example admission routes CPFT Inpatient teams Discharge destinations and potential care teams
CPFT Pharmacy staff contacts Site Fulbourn Hospital Specialty and locations covered Mental Health Cambridge / Huntingdon Phone contact (01223) 219523 Cavell Centre Mental Health Peterborough / Fenland (01733) 776006 Adult / Older People rehabilitation - Cambridge (01223) 219240 Brookfield s Hospital Cambridge Rehabilitation Unit Byron Wards Princess of Wales Hospital Welney Ward City Care Centre "Intermediate Care Unit Adult / Older People rehabilitation Ely (01353) 772535 Adult / Older People rehabilitation Peterborough (01733) 847137 North Cambs Hospital Trafford Ward Adult / Older People rehabilitation Wisbech (01733) 776006
Trust teams and services For full list of services and contacts see our Trust website: www.cpft.nhs.uk - navigate to Our Services
What will we be asking to happen? In the first months we will aim to refer consenting service users that: meeting one or more of the criteria below: Discharge notification form includes a plan with specific medicine instructions to the GP that would require medicines changes post-discharge such as dose adjustments/changes. Patients using compliance aid prior to admission. Discharge documentation has highly specific quantities listed (e.g., in the case of compliance aids, overdose risk, or course lengths of clinical significance). Where there is risk information around medicines access that needs to be shared particularly in younger people. Referrals will use professional judgement too. Future plans to include everyone once DMS is embedded in practice and working as intended.
What kinds of action will we be recommending? All DMS related - Medicines management housekeeping. Supporting adherence. Ensuring the discharge plan goes to plan. Patient check-in . Being vigilant towards risk management issues. We don t set expectations on your involvement with long term follow up. The information may be helpful to you for developing this.
Where we think issues crop up Changes to medicines made when patient goes into multiple care settings (e.g., acute trust, then CPFT unit) Discharge supplies given to patient, but previous medicines supplies already at home or ready in pharmacy. Stockpiling. Confusion over process for getting new medicines again on discharge. Patients going back to old medicines when not used in hospital. Giving up on treatment. Switching/discontinuation plans not taken to conclusion. Emerging adverse effects and impact on adherence.
Child & Adolescent Mental Health CAMH Crisis Team (access via First Response Service 111 option 2) Young people is severe crisis Intensive Support Team (IST) Work with multiple teams to support young people with severe MI CAMH Services (CAMHS) Longer-term mental health support
Adult & Specialist Mental Health Adult Crisis Team / CRHTT(access via First Response Service 111 opt. 2) Adults in acute crisis before and supporting people after admission Locality Teams Location based services for longer term community management of severe mental illness Personality Disorder / Forensic / Eating Disorder Services Specialist out-patient services following up on specific patient groups
Older Peoples Mental Health Older People s Crisis Team Older people in acute crisis before admission. Also supporting people after discharge Neighbourhood Teams Location based multiagency team supporting longer term needs both mental and physical
Adult & Older People Rehabilitation Services typically discharge back to GP for follow up. May have follow-up appointments with local acute trust. Non-mental health. Patient s may be moving back home or to new accommodation (including supported accommodation). Stay in hospital almost always preceded by stay in acute trust first.
Person in crisis what to do? Contact points of note: Service Name NHS First Response Service Samaritans Lifeline SANEline Contact number (and accessible hours) 111 option 2 116123 (operates 24/7) 08088082121 (operates 7pm-11pm) 03003047000 (operates 4:30pm-10:30pm) In an emergency, call 999
