Long-term Care Pathway

This pathway is for people with severe and enduring mental health problems who need specialist hospital care, due to complexity of their condition and/or high risk challenging behaviour such as aggression, wandering or anti-social behaviour.

The emphasis is on person-centred care, enabling the individual to be as independent as possible and achieve a good quality of life. People will remain on the pathway as long as they meet the criteria. Discharge from the pathway will be to a less restrictive environment, eg. nursing or residential home, or transfer to the recovery and rehabilitation pathway.

The multidisciplinary team is experienced in understanding and resolving high-risk, challenging behaviours in a dignified manner.  The holistic, biopsychosocial (BPS) approach supports the person to recover a sense of their own identity, optimising their strengths.  To us, this means paying particular attention to learning about each person’s background, individualising activities and being sensitive to people’s religious beliefs and cultural identities.  Our emphasis on valuing the individual, their history and their lived experience helps us to promote their psychological and emotional wellbeing.

Who will benefit from this pathway?

• A primary presenting problem of challenging behaviour and complex needs eg psychosis or cognitive impairment.
• A background of long term mental illness.
• A significant degree of underlying or co-existing cognitive impairment.
• Men and women who are difficult to be cared for in the community or other care setting due to the severity of their challenging behaviour, including:
  - Verbal agression which puts them at risk of retalisation from others.
  - Physical agression towards others.
  - Sexually disinhibited behaviour.
  - Wandering and absonding.
• Men and women either informal or detained under the Mental Health Act.

What are the objectives of the pathway?

• Creating an environment that is conducive to, and enhances the individual's quality of life.
• Comprehensive and regular assessments.
• Treatment that is focused on reducing the severity and frequency of challenging behaviours.
• Meaningful and personalised activities that maintain and enhance the life skills and interests of our patients through individual and group work.
• Help the patient maintain strong links with family and friends through regular contact and visits.
• Regularly reviewing the effectiveness of care through planned case review meetings with the CPA team.

For information about accessing treatment, please click here.