The Active Transition Program
The Active Transition Program (ATP) is a joint initiative designed in collaboration with Connect (Hohou Rongo House) and Henry Rongomau Bennett Centre (Inpatient Coordination Team) which compromises of 6 beds in the community. The purpose of the ATP is to provide proactive specialist support to services users for 12 weeks who need transitioning from the ward in to a 24/7 residential facility that prepares them for independent community based living. This service initiative commenced on 1 June 2018 and is currently still in the pilot phase.
The clinicians in the Inpatient Coordination Team are as follows:
- Phil Eade (Social Worker)
- Lenna Brindley-Richards (Psychologist)
- Toni Djohanli (Charge Nurse Specialist)
- Alex Luka (Occupational Therapist)
- Divika Reddy (Occupational Therapist, 0.5 FTE)
Hohou Rongo House has a team of 5 support workers and Selena as the Service Manager and LinkPeople have allocated a staff member (Jo Smythe) on a 0.5 FTE.
Clients are chosen for the program if they have:
- no fixed abode or have an unstable/unsafe living situation
- the potential to transfer to independent living situation after 12 weeks
- demonstrated some motivation to engage
- moderate level of self-regulation to reside in a shared living environment at Hohou Rongo House.
- Clear exit plan (identified in the ward) after 12 weeks
The Inpatient Coordination team attend ward meetings every morning to identify appropriate service users for this programme. The referral process includes the following documents:
- Comprehensive Assessment
- Functional Assessment
- Cognitive Screening Assessment if deemed necessary
- Mental Health information and Risk Management plan
- Cultural assessment (Kaitakawaenga)
The referral documents are sent to Selena and Divika who visit these service users in the ward for an informal meeting before a final decision is made. Initially, the service user enters a bed at Hohou Rongo on respite for 7 days. After this timeframe a discharge meeting is held at the ward before the service user officially enters the programme. The service users and whanau are informed of the discharge date after being accepted into the programme.
It is worth noting that Divika implemented a model of care framework called Residential Rehabilitation Pathway (RRP) within this programme as part of her CASP. The objective of this framework is as follows:
- To improve the residential rehabilitation pathway for service users living in residential recovery service through an iterative person centred process.
- A framework that guides clinical practise which fits around the service users’ occupational needs and collaborative approach with stakeholders which has a culturally sensitive approach.
- To apply occupational therapy interventions to improve/develop baseline functioning of the service users in preparation for community living.
For the first 6 weeks the service users are encouraged to:
- Actively engage in occupational based recovery goals identified with Divika and Hohou Rongo staff:
- Attend 1:1 (or group) therapy intervention with Divika such as anxiety management training, Cognitive Remediation Therapy (alongside Alex), Sensory Processing, and group programme such as the Wellness In Everyday Living Program (WIEL), Let’s Talk, Kai Time, Slippery Slope, Living with Senses, BusIT, Bus n GO.
- Attend day activities with community support agencies such as Progress to Health, Centre 401, IRS (Integrated Recovery Services Waikato DHB), therapy groups held at London Street (Waikato DHB Community Mental Health Team) and Sports Waikato.
Whilst encouraging routine and structure to improve occupational performance free time is also factored in to the service users weekly schedule. During this timeframe Divika will send referrals to external agencies such as LinkPeople, Workwise, Mental Health NZ, Pathways Community Mobile Team, Emerge Community Mobile Team, and Pai Ake Solution to provide wraparound support with recovery goals post discharge from the programme. These referrals are sent according to the service users individual occupational support needs.
A weekly evaluation and planning meeting is held onsite with Lenna (or other ICT member in her absence), Divika, Glenda, Selena and Jo to discuss each client’s recovery progress during the week and create action plan for the following week.
At the 6 week stage, Divika will schedule a review meeting with all stakeholders (including service user, whanau, Lenna, DHB keyworker, Selena, and external agencies) are invited to attend. During this meeting the service users recovery process is evaluated and collectively a robust discharge plan is created with the focus of wraparound support to ensure smooth transition into the community. The service users exit plan into appropriate accommodation is determined post discharge and a discharge date is confirmed.
Active discharge planning from the programme then begins from week 6 to week 12 according to their agreed plan at the review meeting. During the final week of the program the service users and whānau are asked to fill out an ATP Feedback form.
Post discharge all stakeholders are invited to attend client graduation ceremony to celebrate the service users recovery success and for completing the 12 week programme.
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