The Dynamic Support Pathway (DSP) is a pathway designed to monitor and track those individuals known to NHS Herefordshire and Worcestershire Integrated Care Board (ICB), who are at the highest risk of admission to specialist in patient – locked, secure and T4 hospitals.
The Dynamic Support Pathway aims to ensure that:
- All appropriate Health, Education and Social Care services are working together
- People receive the right care and treatment, when they need it
- Crisis is prevented
- Risk factors are managed to prevent admissions to Tier 4 in-patient services, locked and secure services.
There is a Dynamic Support Pathway panel for adults and children in place, in both Herefordshire and Worcestershire. The Terms of Reference provides further information around the panel’s function.
This Dynamic Support Register (DSR) is held by the Head of LDA Admission Avoidance and Discharge on behalf of the NHS Herefordshire and Worcestershire Integrated Care Board (HWICB).
The person is required to have a formal diagnosis of a Learning Disability and/or Autism.
(please note: Evidence of the formal diagnosis will be required to support the referral)
The person is required to meet a minimum of two elements of the criteria below. Additional information will be discussed at DSP panel to further understand the risk factors and inform the Red/Amber/Green (RAG) rating for the DSP:
(For more information on the RAG rating, see the DSP Support Tool section of this webpage)
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Criteria |
Supporting information |
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1 |
A recent history of multiple placement breakdown – this is more than one breakdown within a 6-month period. |
Crisis team involvement and engagement with services. Period of allocation. Requiring specialist interventions from community LD or MH teams. |
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2 |
Individuals with multiple risk factors with a diagnosis of LD and/or Autism who present with risky behaviours that place themselves or others at risk of harm, placing their placements at risk of breakdown. Supported in an unstable environment or by a changing staff team leading to risk of admission. |
Details of risk factors is the person in a specialist service, what mitigation is in place ie PBS plan in place, risk assessment, crisis plan, levels of staffing required to manage the risk. IST involvement. |
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3 |
Individuals presenting a high risk of admission/readmission (inclusive of those on S117, CTO (Community Treatment Order), Guardianship orders, subject to DoL (Deprivation of Liberty)) to T4, locked and secure in-patient services. | History of (re)admission(s). Evidence of DoL currently in place, copy of S117 plan, evidence of restrictions. |
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4 |
In acute Mental Health ward settings and/or detained under Mental Health Act. With mental health needs, including disordered eating/avoidant restrictive food intake disorders. Risk of harm to self and others. Presenting ‘in crisis’ at A&E department. | Crisis plans, evidence of admission dates, frequency of A&E attendance, 136 suite attendance. Details of detainment. |
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5 |
Family carer or provider breakdown and/or no fixed address, leading to crisis with increased risk factors. Family carer and/or provider showing increasing concerns and challenge to ensure needs that prevent a mental health crisis are being met.
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Evidence to support the crisis/breakdown. Evidence of what support has been offered and current involvement from community teams. |
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6 |
Individuals with a high risk of offending or reoffending known to services requiring additional support around risk management. In contact with the criminal justice system. In receipt of service from youth offending teams. | Allocated professionals to provide a copy of MDT action plan in place aimed to mitigate risk factors. |
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7 |
Those CYP in welfare secure placements or in 52-week residential placements. |
Funding stream (LA or CHC). Area of placement and support network. Type of placement (education supported living etc). Has the receiving ICB been notified? |
Consent to be on the DSP is required from the person. Consent is reviewed annually according to the policy.
The referrer must ensure that the person they are referring to the DSP, has provided their consent, or they have completed and submitted the best interest decision documentation, following a Mental Capacity assessment. All documents must be submitted to the LDA-AAD team aligned with the referral process.
This is a self referral section for the Learning Disability and Autism Dynamic Support Pathway.
Helpful information
If you (or the person you want to refer) has a Learning Disability or you are an Autistic person and you think that you are risk of being admitted to a specialist Mental Health Hospital and you are registered with a GP in Herefordshire and Worcestershire, then you (or person who you would like to refer) may meet the criteria for the Dynamic Support Pathway.
The pathway is designed to help you get the right support when you need it, and it also helps to bring our local Health, Education and Social Care services together. We aim, when possible, to avoid admissions into specialist Mental health Hospitals by working together. If admission cannot be avoided, then we continue to work with you to reduce the length of your stay and we ensure you have the treatment you need and you understand what you need to do to support a timely discharge.
Please note: We do not proceed with any Dynamic Support Pathway referral if person did not provide informed consent.
We will talk to you about consent, once we have received your referral. It is important to know that yours or person’s current support will not be affected if you decide you do not want to be on the Herefordshire and Worcestershire Dynamic Support Pathway.
Please note: Our local processes are directly linked into the Dynamic Support Pathwayand this ensures that our local Health, Education and Social Care systems will be informed and respond in a timely way during periods of crisis. Therefore, there may be a delay if you or the person you are referring is not known to the Dynamic Support Pathway.
If person you are referring to Dynamic Support Pathway doesn’t have capacity to give informed consent, a best interest decision will need to be made under the Mental Capacity Act. We will speak to you about this when we receive your self- referral for the Dynamic Support Pathway.
Please note: When someone is registered on our Dynamic Support Pathway the NHS Herefordshire and Worcestershire Integrated Care Board (ICB) will hold the following information about you:
- Name
- Date of birth
- Address
- NHS number
- Your diagnosis details
Please note: to meet the criteria you will need a formal diagnosis of a Learning Disability and Autism.
The team will also need to know the following information about you, this will be shared with the identified services that will aim to help you reduce any risk factors to support you to remain in your home if it is safe to do so, and to avoid admission.
- The names and contact details of professionals that are supporting or working with you.
- Your current concerns including risk factors that you feel may lead to a specialist mental health hospital admission.
- What strategies have you tried to reduce risks factors that you feel were helpful (including positive strategies to improve a person’s quality of life, increasing life opportunities and self-esteem).
- What do you feel could be useful to reduce risks further.
- Any action plans moving forwards including recommendations for current and potential future services.
Please note: If the person is added to the Dynamic Support Pathway, you will be consenting for us to share your information with professionals from our local NHS services, Education and Local Authority Social Care teams, from following organisations:
- Worcestershire County Council
- Herefordshire Local Authority
- NHS Herefordshire and Worcestershire Integrated Care Board
- CAMHS services
- NHS Intensive Support Teams in Herefordshire and Worcestershire
- Herefordshire and Worcestershire Health and Care Trust
- Worcestershire Acute Hospital Trust
- Wye Valley Hospital Trust
- NHS England
- Reachout Mental health collaborative - Commissioning Hub (NHS)
- Mental Health Teams across Herefordshire and Worcestershire
- Learning Disability Community Teams across Herefordshire and Worcestershire
Next steps:
- Please complete the form below and provide us with the information we require to consider your referral to be on the DSP.
- The Learning Disability and/or Autism Admission Avoidance and Discharge (LDA-AAD) team will contact you/person within 5 working days to discuss the referral.
- You will be offered a phone call, or we can set up a team’s call/meeting if you provide us with your email address.
- At this first meeting the team will collect further information, this is to help us to understand your current needs, levels of risk and what support you may need.
- The referral will be discussed at the next Dynamic Support Pathway panel, you will be informed if you have been accepted onto the Dynamic Support Pathway.
- If your referral is not accepted, we will let you know why in a letter that will be sent to you at the address you have provided.
All referrals will be triaged in the same way required to meet the Dynamic Support Pathway criteria, the Dynamic Support Pathway panel will make the final decision based on the information provided.
Please note: The Learning Disability and/or Autism Admission Avoidance and Discharge Team (LDA-AAD) does not provide an emergency crisis response service, we are a team that navigate services on your behalf and will bring our local Health, Education and Social care systems together to help you get the right support when you need it. The team works flexibility between 8am – 5pm Monday to Friday (the team does not work weekends or Bank holidays).
To complete a self-referral form, click this link: Dynamic Support Pathway Self Referral Form
The LDA – Admission Avoidance and Discharge Team (LDA-AAD) hold DSP weekly meetings across the system. Facilitating a monthly review within x4 DSP panels:
- Worcestershire - Over 18 years (divided into 18-25 years and over 26 years)
- Worcestershire - Under 18 years
- Herefordshire - Over 18 years (divided into 18-25 years and over 26 years)
- Herefordshire - Under 18 years
Each meeting is chaired by LDA-AAD Clinical Commissioning Lead, and the panel has additional representatives from NHS HWICB, Senior Leads from Herefordshire and Worcestershire Local Authorities, Herefordshire & Worcestershire Health and Care Trust – LDA and MH Community Services, and Continuing Health Care (CHC).
The DSP is used to inform Health and Social Care Commissioners of the commissioning intentions, to develop and provide community-based services that are sustainable, and support people to remain in their local communities, near to their families and friends.
The criteria is also designed to monitor those people in a 52-week out of county residential placement for Children and Young People (CYP) with a diagnosis of Learning Disabilities and/or Autism.
The pathway is dynamic, in that people move through the pathway, dependant on risk factors directly linked to admission avoidance.
The Dynamic Support Register also includes those people in in-patient specialist T4 CAMHS, locked and secure services. These people are reviewed outside of the regular DSP meetings.
All new referrals are triaged by the LDA-AAD team for eligibility to the DSP and taken to the next DSP meeting. DSP panels members review using the Clinical Support Tool, with consideration to the supporting information provided both on the referral form; and information shared by the DSP panel member during the review.
- The Clinical Support Tool will indicate a Red, Amber or Green (RAG) rating for the DSP.
- The panel will then cross reference the Clinical Support Tool rating against the DSP RAG rated risk of admission to specialist T4 CAMHS, locked and secure services.
- The DSP panel agree the formal RAG rating and place on the DSP.
- New referrals will only be accepted onto the DSP if they are RAG rated Red or Amber. Any new referrals RAG rated Green will be declined.
- The individual and the referrer will be informed as appropriate and accessible information will be provided about the LDA-AAD team and the Dynamic Support Pathway.
