Q: ‘We have received criticism for not providing clear patient pathways on exit from our residential treatment service. We are very focused on aftercare and have strong relationships with the fellowships and other community groups – however these are informal and we do not have documentation. How should we present our evidence to demonstrate that this is provided by our service?‘
A: Whilst the question does not confirm whether the criticism originates from CQC, the local authority or a third party commissioner, the simplistic answer remains broadly the same: to refer to the standards against which you are being measured (whether CQC or local authority best practice) and ensure that you produce the available evidence in the recommended format. The easiest way to demonstrate compliance is to use the language of the body assessing you.
For example, within their specialist substance misuse services provider handbook, July 2015, CQC set out their commitment to focusing on “transitions between services, care pathways and joint working as part of our inspections of specialist substance misuse services”. It highlights the importance of addressing both physical and mental health needs and enabling service users to achieve a good quality of life by assisting with aspects of wellbeing such as housing, employment and social participation. CQC always focuses upon the ability of services to provide a holistic person-centred approach, with appropriate integration of healthcare professionals, to meet the individual’s needs and expected outcomes.
A service looking to demonstrate compliance, therefore, would ensure their policies identify stages during treatment when post-rehab support is discussed and advice given. Care plans and patient notes should record these conversations, include evidence of when and to where individuals were signposted, and after care organisations should be required to provide confirmation of arrangements made with individuals prior to discharge from the service.
However, that is easier said than done if, as the question describes, the relationships are informal. My preliminary advice would be that you should begin now to formalise those relationships so that you do not encounter the same criticisms again. Services are expected to be able to provide documented proof of an integrated care pathway, from initial assessment through to post-treatment referrals and aftercare plans. The structure of the aftercare support will of course differ dependent upon client presentation, but your policies and procedures should set out the factors taken into account at each stage of the treatment process when identifying the appropriate aftercare for the individual. Your protocols should list the organisations and groups with which you have relationships and on whom you rely for aftercare, and should identify which types of service users are suitable for referral to which group. Finally, your files should demonstrate that you put those policies, procedures and protocols into practice.
In circumstances where you have yet to draft formalised policies, I would suggest obtaining as much evidence of your actual practices as possible. Examples could include statements from the groups themselves detailing their interactions with you, questionnaires completed by service users confirming their aftercare provision and excerpts from care notes highlighting when aftercare was discussed and agreed with individual service users.
The question of what appropriate aftercare looks like is a timely one. The inspection system for substance misuse services is currently being re-evaluated by CQC, with the expectation that more services will become subject to regulation than ever before; among those will be certain categories of after-care. Whilst regulation carries with it added burdens, this may assist services by providing structured expectations and reducing the chance that services are caught out by not appreciating the need for formalised policies.