72 hour follow up technical guide

1 Aim

The aim of this technical guide is to support operational services in the coordinated delivery of 72 hour (72HFU) and 7 day (7DFU) follow up for all patients discharge from all age acute mental health, psychiatric intensive care (PICU) and mental health rehabilitation wards.

2 Scope

This guide applies to all staff working within adult mental health, older adult mental health and mental health rehabilitation wards, secondary care community mental health services including early interventions and assertive outreach teams across the trust.

3 Link to overarching policy, and or procedure

This technical guide should be read in conjunction with the following documents:

the trust’s healthcare record keeping policy
the trust’s Disengagement policy
the service specific process maps
the SystmOne user guides and videos (staff access only) (opens in new window)

4 Procedure or implementation

The period following discharge from mental health inpatient units to community settings can come with increased risk of self-harm. Findings from the national confidential inquiry into suicide and safety in mental health showed that most post-discharge deaths by suicide occurred in the first week after leaving inpatient care, with the highest frequency on the third day after discharge. Many of these people died by suicide before their first follow-up appointment. Based on this new evidence and in line with the national and local KPIs the trust is committed to deliver post discharge follow up within 72hrs for all patients discharged from acute inpatient care and follow up within 7 days for all patients discharged from rehabilitation wards.

4.1 What bed types are in scope?

Bed types in scope include non-specialist CCG-commissioned adult inpatient care.

72HFU:

acute adult mental health care
acute older adult mental health care (organic and functional)
psychiatric intensive care unit (acute mental health care)
locked rehabilitation

7DFU:

high dependency rehabilitation
long term complex rehabilitation or continuing care

4.2 Which patients are in scope?

All patients discharged from an integrated care board (ICB) commissioned adult acute mental health inpatient or rehabilitation bed to their place of residence, care home, residential accommodation, or to non-psychiatric care.

Patients excluded from follow up include:

patient’s readmitted within the follow up period including those admitted via section 136 (gateway and admission counts as an assessment)
where legal precedence has forced the removal of a patient from the country (discharge reason ‘discharged, out of country’)
patients who have died within 72hrs of discharge (referral reason or SPINE update) (discharge reason ‘discharged, patient died’)
patients transferred to NHS psychiatric inpatient ward (discharge reason either ‘transferred, to locked rehabilitation providers’ or ‘transferred, to other low secure providers’ or ‘transferred, to other medium secure providers’ or ‘transferred, to out of area ward’)
patients transferred to a non-NHS hospital (discharge reason ‘transferred, to non-NHS hospital’)
patient discharged from child and adolescent mental health Services (exclude 17 and under)
patients discharged to prison (discharge reason ‘discharged, to prison disposal via courts’), please note this is different to police custody which is not out of scope
patients from outside of England, for example, Scotland and Wales (discharge reason ‘transferred, to out of area ward’)
patients where the trust are not the local provider (GP at time of discharge, automatically pulled from SPINE)
patients who are discharged out of area into the community (discharge reason ‘discharged out of area, follow up agreed by out of area team’)

4.3 When does the follow up start and when does it end?

Compliance with both periods is measured in days, not hours and starts the day after the person is discharged from hospital, for example, If someone were discharged on the first of January, they could be followed up on the second, third or fourth January to comply with the 72hr time-period or second to eighth to comply with the 7DFU time-period. Weekends and bank holidays are counted.

4.4 Who is responsible for undertaking the follow-up?

The follow up should be completed by the local NHS mental health provider that has responsibility for the person’s ongoing care. In most cases, this will be the organisation that has been providing the inpatient care for the person. An exception to this would be where the person has been placed out of area for their inpatient care due to lack of a local available bed and are discharged directly to their local community team. In this case, the person’s local provider would be responsible for the follow-up post discharge, not the organisation that delivered the inpatient care out of area.

Patients discharged outside of the trust commissioned areas should receive follow up by their local provider. The discharging ward should contact the local provider and request post discharge support either by the appropriate community team or the local home treatment team. The plan for follow up should be clearly documented in the patient discharge summary and the discharge reason should be selected as ‘discharged out of area, follow up agreed by out of area team’. Where arrangements cannot be made, the discharging ward must attempt to make telephone contact with the patient within 72 hours of discharge. Patients will only be excluded from the follow up report when their address or GP is recorded in SystmOne as being outside locally commissioned services.

If a patient receives contact following discharge (pre 72HFU) that was not intended to fulfil or does not fulfil the follow up requirements, then the planned follow up must still go ahead.

4.5 Local responsibilities and process for undertaking follow up

Discharge planning should begin at the point of admission. Inpatient services must initiate discussion with the community team who will be responsible for follow-up at the earliest opportunity.

All new referrals to community teams should be managed in accordance with local process.

A follow up method, date, time, and location must be agreed with the patient before they are discharged from the ward and detailed in the discharge care plan. Consideration must be given to the day of discharge and ability of the community team to provide follow up.

Where there are challenges informing the community team of discharge an email confirming discharge should be sent by the discharging ward to the appropriate community team using the admin emails (see appendix A).

It has been agreed locally that the following teams will be primarily responsible for undertaking follow up for the patient groups indicated:

Follow ups
Patient group or type	Team responsible for follow up
Open to a Secondary Care Treatment team	The responsible Secondary Care Treatment team
Not open to a Secondary Care Treatment team	The access or crisis or home treatment team for the area in which the patient resides
Transferred to any other ward or facility (apart from the patients excluded in 4.2 of this guide) including care homes	The transferring ward will make telephone contact
Outside the trust’s commissioning area	Local provider where possible or discharge ward by telephone where this is not possible

However, for patients open to a Secondary Care Treatment team and where part or all the 72HFU period falls over a weekend or bank holiday, or the patient is unavailable for an appointment within normal working hours; the responsible team should coordinate follow up with the Access Home Treatment team who will complement the support already on offer by the responsible treatment team and where required facilitate the follow up, for example, if the patient is discharged on a Thursday the Treatment team would make their first attempt at contact on Friday and if unsuccessful the Access Home Treatment team would follow up on Saturday and Sunday. Treatment teams must make every effort to undertake the follow up as agreed and should avoid unnecessarily placing the burden on Access Home Treatment teams where possible.

It is agreed locally that a face-to-face contact should be offered to all patients discharge to a non-supported residence in the first instance and should be promoted to the patient as best practice.

However, where assessed to be clinically appropriate or the patient is discharge to a hospital, care home or supported living environment, or indicated as the patients preferred choice of contact, arrangements can be made to contact the patient by telephone, Airmid, MS Teams or other suitable technology. Where a patient is discharged to hospital, care home or supported living environment attempts should be made to speak to the patient directly, however where this is not possible an update from a care provider is sufficient. While this type of contact within the required timeframe counts as compliant with the national and local target, it does not replace the need to undertake a face-to-face contact, which should be arranged at the earliest opportunity (where clinically appropriate).

Where a face-to-face contact has been agreed and the patient does not attend, the team responsible for the follow up should attempt to establish contact with the patient at the earliest opportunity and re-arrange a further face-to-face.

This must be recorded using the following save option:

72hr discharge follow up DNA

If face-to-face contact is not achieved after two attempts a follow up should be attempted by telephone or other suitable technology.

If the team responsible for follow up is unable to make any contact with the patient post discharge, then they should refer to the trust’s disengagement policy for escalation and guidance.

All follow up contact should be undertaken and recorded using the subjective, objective, medication, risk, assessment, plan template (SOMRAP) to support a comprehensive assessment of the patient’s presentation, risk, medication efficacy and concordance (where appropriate) and the formulation of a plan. This should be recorded via the action in the discharge care plan which will link staff to the SOMRAP template.

All follow up contact must be saved using one of the following ‘save’ options:

72hr discharge follow up face to face
72hr discharge follow up telephone

4.6 Patients who decline a follow up

Every effort must be made to explain the importance of a follow up to the patient, however where a patient exercises their choice not to receive any community follow up post discharge this should be accepted. The patient’s decision must be recorded in the discharge summary and the patient discharge care plan must include details of how they can contact services for support.

4.7 How will data be managed and reported locally?

All patients eligible for a 72H or 7 day follow up will be presented in Re-portal report 368 ‘follow up report’.

All services in scope of this target must have local arrangements to monitor the report daily.

Patients will be removed from report 368 once a follow up contact is recorded using the appropriate save options in SystmOne.
Patients who are assessed under section 136 (within their follow up timeframe) but not admitted following the assessment will be counted as having received a follow up. A 136 assessment is a formal assessment under the Mental Health Act and is therefore considered locally to meet the standard of assessment expected for the purpose of a post discharge follow up.

Patients who have not been seen within 90 days will move to an archive page (page 4 of report 368).

For reporting compliance, a patient who cannot be reached for follow up or decline a follow up will be counted as having not been followed up. However, to maintain a clear and accurate report at operational service level these patients will be removed or excluded as follows:

patients who decline a follow up prior to discharge (captured via discharge summary)
patients who DNA will remain visible on report 368 until one of the appropriate follow up save options are entered
the patient declines follow up (captured via discharge options)
the team responsible for follow up determine that the patient has disengaged (captured via discharge options)

4.8 Escalation process

Any breaches must be escalated to the appropriate service manager and the Performance team at the earliest opportunity.

Non-compliance with this guidance documents should be escalated to the appropriate service manager at the earliest opportunity.

5 Appendices

5.1 Appendix A

Page last reviewed: April 23, 2024
Next review due: April 23, 2025

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