About The Team

The Learning Disability and/or Autism Admission Avoidance and Discharge Team (LDA-AAD) work across Herefordshire and Worcestershire Integrated Care Systems (ICS) inclusive of Health, Education and Social Care to support the programme delivery. LDA-AAD team works together with self-advocacy groups, Health, Education and Social Care Partners to coproduce and develop the support needed for implementation of the Care, Education and Treatment Review policy and-guide.

The LDA-AAD team works hard to ensure that the policy is delivered and embedded into our local systems, tracks and monitors the national LDA trajectories around the use of specialist Mental Health hospitals. We share information with our Partners to inform commissioning intentions across our local systems, this is aimed to inform the development and review of community services. To achieve this, the LDA-AAD team was developed, and it includes the following roles and responsibilities. The head of service and the clinical posts are required to have clinical knowledge and understanding of LDA and Mental Health services, behaviour and risk management. They also oversee quality assurance for the specialist services commissioned by the NHS Herefordshire and Worcestershire Integrated Care Board (ICB).

Head of LDA- Admission Avoidance and Discharge - Working across all ages. Post holder is responsible for the implementation of the Admission Avoidance and Discharge pathway. The post holder has commissioning responsibility for Learning Disability and/or Autism locked Specialist Mental Health Hospitals, on behalf of the ICB. Specialist Mental Health hospital services are commissioned for people, often following an assessment under the Mental Health act, where detainment is being considered due to presenting risk factors following assessment and a Care, (Education) and Treatment Review (C(E)TR). The services are only commissioned on a need led basis. The LDA-AAD team continue to monitor and track people detained in Child and Adolescent Mental Health Services (CAMHS) T4, locked and secure services, alongside monitoring those at high risk of admission, these people will be on our local Dynamic Support Pathway (DSP). Post holder heads up the service and provides leadership for the LDA-AAD team.

LDA Clinical and Commissioning Lead – There are two post one working with under 25 -year-olds, and the second post working with over 18-year-olds. Post holders are responsible for clinical and commissioning oversight. The post holders chair the Dynamic Support Pathway (DSP) meetings and monitor and review people across the pathway, who are registered on the Dynamic Support Pathway (DSP), including those who are in specialist Mental Health hospitals. Post holder provides clinical supervision and management to the team according to the team structure.

Care and Treatment Clinical Reviewer – The Care and Treatment Clinician will complete face to face visits to those in specialist Mental Health hospitals, as per the guidance from the Dynamic Support Pathway and Care, (Education) and Treatment Reviews policy. The post holders have responsibility for chairing the community/pre-admission, in-patient, and post discharge Care (Education) and Treatment Reviews (C(E)TR). The post holders will review the C(E)TR actions, and ensure that treatment and rehabilitation goals are clear, achievable, and progressing to support timely discharges. Post holders provide clinical supervision as per the team structure.

Discharge Liaison Nurse – Working with over 18 years. The post holder is responsible for reviewing everyone in locked and secure in-patient settings to support timely discharge and monitoring their progress against 12-point discharge plan. Post holder also reviews C(E)TR actions and reports any blocks or barriers to the Care and Treatment Clinical Reviewer.

LDA System Navigators – working with under 25-year-olds. The System Navigators work with those young people known to the Dynamic Support Pathway with a DSP RAG rating of Red or Amber who are living in the community but are at risk of admission to specialist Mental Health hospitals. The post holders also work with those detained in CAMHS T4, locked and secure hospitals. Their role is to navigate Health, Education and Social Care systems to ensure that people are receiving the right care and support when it is required to assist with a timely discharge.

LDA Project Support Officer – Post holder works with the head of LDA-AAD, and the LDA Clinical and commissioning leads, providing project management support to fulfil the programme and its effective delivery. Post holder collates and analyses the data, completes any required reporting for NHS England and our local system delivery. Post holder monitors and tracks the Dynamic Support Pathway and provides supervision as per the structure.

LDA Business Support Assistant – Post holder provides all business support to the team as and when required monitors the team inbox, processing referrals at the point of contact with the team. The post holder coordinates and tracks C(E)TR training workshops. Post holder provides business support to the Dynamic Support Pathway panel members and arranges the C(E)TR meetings, including identifying and matching the panel members.

Link System Navigator – working with under 25-year-olds. Post holder sits within SENDIAS services. This post is integral to the pathway, offering on-going support and guidance to the young person, when they are stable and no longer are required to be on the Dynamic Support Pathway. The Link System navigator can continue to follow up on any recommendations around education needs. The LDA-AAD team will complete the transfer of the young person to Link System Navigator with young person’s agreement if required.