We deliver safe and effective inpatient post-detoxification, recovery-focused care for people who sleep rough, are in hostel accommodation and/or are at risk of returning to the streets.
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REBUILD Pathway admission criteria
Patients are admitted to Mildmay after being stepped down following detoxification treatment at acute centres in London like the Addiction Clinical Care Suite for homeless people at Guys and St. Thomas’s Hospital - one of our partners in this programme.
Description of Service
Patients on this pathway receive support and expert care from a full multidisciplinary team throughout their treatment journey, from initial referral through to discharge and aftercare.
Mildmay’s long experience has created numerous transferrable skills within our expert multidisciplinary team. We strive to accomplish the best possible outcomes, supporting individuals to achieve and maintain the greatest possible degree of independence.
We currently provide four post-detox inpatient beds
This capacity has been carefully balanced against the requirements of our existing specialist care pathways, including HIV neurocognitive and physical rehabilitation, step-down homeless care and Covid-care for patients who are homeless.
Those admitted to the service are located in a dedicated section of the ward to maximise peer support and create a safe environment conducive to recovery. All patients under the post-detox pathway are allocated private, ensuite rooms within our modern, purpose-built facility.
Many patients under our existing pathways are vulnerable, for example, due to cognitive and physical impairments, complex safeguarding and psychosocial issues and they may for example be survivors of intimate partner violence. Therefore, our multidisciplinary and management teams are sensitive and experienced in relation to issues of safety, and all our patient accommodation is private and ensuite.
Our nursing team check all patients at least hourly, to further ensure safety. Communal areas are monitored by CCTV. We have security on site until 11 pm Mondays to Fridays and this is continuously reviewed, and increased by the Estates and Facilities Team if necessary depending on risk assessment.
How we help this group
Our multidisciplinary clinical team has expert knowledge of pathways of disease, their progression and treatment, including disorders associated with substance misuse. We provide a model of care aimed at restoring the individual’s independence and facilitating motivation towards recovery. We address psychological and social needs through a multidisciplinary approach. Our model is sensitive to different cultural needs and holistic in its nature, engaging with a range of professionals to meet identified needs. This background ideally positions Mildmay to deliver high quality, patient-centred, supportive, individualised post-detox care.
Our approach to managing this service is evidence-based and complies with current standards and practice guidance including UK guidelines on clinical management, NICE and CQC regulations. As an organisation, we are responsive to changes within national guidelines. The service is individualised, effective and innovative and underpinned by clear guidance and prescribing protocols. All patients participate in the development of bespoke, multi-disciplinary care plans*.
*Each patient is fully involved in planning their care, which is tailored to take personal preferences and individual circumstances into account and meet the specific medical and psychological needs of the individual, generating a sense of ownership.
Background to skills and knowledge
Through the delivery of the HIV, Homeless and Covid Care Pathways, our medical, nursing and therapy teams have developed clinical expertise in the care and management of patients who have substance misuse needs and complex co-morbidities and the relevant protocols to deliver the post-detox pathway safely. For example, currently:
We prescribe opiate substitute treatments to patients withdrawing from opiates.
The nursing team are experienced in the administration of prescribed and controlled substances and the organisation has an Accountable Officer
Our team is experienced in the safe management of alcohol withdrawal, including prescribing and monitoring side effects and symptoms.
We provide advice and support in smoking cessation and nicotine replacement therapy.
A daily programme of one-to-one and group interventions provides meaningful occupation, whilst evidence-based psychosocial input engenders a deeper understanding of substance misuse and improves motivation to rehabilitate.
We aim for the programme we offer to be varied, and in addition to health promotion and talking-therapy sessions, we provide holistic input such as art therapy, access to gym groups and access to spiritual support via our multi-faith and multi-denominational chaplaincy team. Individual health and wellbeing needs are assessed and addressed through access to a multi-disciplinary team plus external referrals where necessary to ensure that all patients’ needs continue to be met post-discharge.
Safety is at the forefront of all our care delivery and we ensure that local and national infection control and Covid guidelines are adhered to at all times, therefore it is possible that there may be periods when external guidelines may impact the delivery of group sessions, however, if this occurs we endeavour to increase the delivery of 1:1 care input. Staff to client ratio is proportionately high, affording significant opportunities for planned and unplanned interventions.
Efficacy of interventions is measured by the domains of our outcome tools, capturing progress towards recovery with particular attention to recovery capital. With a longstanding proven ability to self-monitor our practices and outcomes and utilise qualitative and quantitative data reporting methodology, monthly and quarterly evaluation of outcomes inform commissioners of performance measures.
A final assessment is undertaken prior to discharge, with a care plan completed on departure that includes contact details for all providers involved in the individual’s care and ensures there is no gap.
We liaise with external organisations such as inpatient detox facilities, rehabilitation units, homeless hostels, community drug and alcohol teams, community mental health teams and homeless pathways teams in relation to each individual patient, ensuring that each discharge is planned carefully with the patient’s input and consent and that patients continue to access the best possible support, dependent on their individual circumstances.
Our Admissions Manager, Housing Officer and Social Worker, in particular, have well-established links with relevant agencies. Our Substance Misuse Recovery Worker is supported by our key partner Resolve, a charitable organisation based in Hertfordshire with extensive experience working with people who are recovering from substance misuse and people who are homeless.
Formal and informal service user feedback mechanisms will continue to ensure expert involvement in the design and delivery of a safe, accessible, and effective service and we will continue to work with individuals in our care to embed continuous improvement.
With an extensive experience in partnership working under its existing pathways, Mildmay recognises the importance of building effective relationships with external partners for example referring organisations. It is vital to ensure that procedures including referrals are well-coordinated, provide the right level of information, and are safe for the individual involved as well as appropriate for the service.
Mildmay is a specialist voluntary sector hospital with an extensive history of supporting patients with complex physical and mental health needs in addition to co-morbid substance use, including patients whose needs make them too complex/risky to be accommodated in a non-medically managed setting.
For over thirty years Mildmay has provided specialist HIV care to complex patients many of whom have multiple co-morbidities as well as diverse and complex psychosocial needs including substance misuse. Many of Mildmay’s HIV Pathway patients have also been homeless.
Mildmay already provides a specialised pan-London pathway for patients who are homeless and have experienced a significant decline in their health, requiring hospitalisation for a wide range of conditions, including renal failure, amputation, traumatic injury requiring wound care, poorly controlled Diabetes, liver disease, cancer, COPD, and many others.
Managing complex co-morbidities
The people we support are diverse. We have decades’ experience caring for patients with advanced HIV infection and its sequelae, in terms of the physical complications of disease, and behavioural, psychological and complex psychosocial aspects. Many people we support are from stigmatised communities (LGBTQ+, intravenous drug users, immigrant communities). Most service users within our HIV pathway have advanced HIV disease and significant numbers are affected with HIV related brain impairment. There are high rates of mental illness in both pathways, and many have significant drug and alcohol misuse problems. Sensitivity to the Equality Act’s 9 protected characteristics i.e. age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and sex underpins Mildmay’s core values and the essence of care delivery.
Our considerable experience of working with people with a range of chronic or acute mental and physical health needs encompasses, across all our existing care pathways:
respiratory illnesses including COPD
hepatobiliary, musculoskeletal, and neurological complications of disease
Psychosis, depression, and schizophrenia
Alcohol-related liver disease
Drug and alcohol use
In addition, complex psychosocial and safeguarding care needs have included:
Complex immigration issues
A significant number of patients particularly under the HIV pathway have been assessed as lacking capacity and have been placed under Deprivation of Liberties under the Mental Capacity Act.
Our team includes colleagues from the range of disciplines one would expect in a hospital, but our small size enables a greater level of cross-boundary working, making us adept at the management of complex co-morbidities and creating individualised approaches to care. Staff have time to build therapeutic relationships with patients and provide additional support beyond clinical care, individualising their approach to better meet needs, and reduce repeat admissions. Detailed multidisciplinary assessments feed into personalised treatment and risk management plans that incorporate physical, mental and social care needs, including sexual health, nutrition, housing, and behaviour management.
Each service user has daily multi-disciplinary input from a skilled and highly-qualified team of medical professionals, plus psychosocial and peer support and practical help from our social care team.
We work with professionals from a range of organisations to provide coordinated care, including social care, for example, we have experience of working with care homes, community psychologists and local authority colleagues to secure social care placements for individuals whose health precludes them from returning home.
Our long-standing tradition of working with external clinical partners ensures that patients receive the best person-centred clinical care. We have strong relationships with infectious disease teams, HIV teams, hepatology and neurology teams across London. Some of our staff work in shared roles for Barts Health NHS Trust and East London Foundation Trust which means links to further specialist care is available.
Our rehabilitation work is focused on measurable outcomes, and we provide data to UKROC (UK Rehabilitation Outcomes Collective). We have relationships with community substance misuse providers e.g. CGL, Turning Point, WDP, SLAM and CNWL, and an SLA with Resolve which will provide additional support to Mildmay specifically in relation to substance misuse and homelessness.
Our team is experienced in working in collaboration with service users while setting achievable and realistic goals. Cross-disciplinary learning will flourish through sharing of resources, daily handovers, weekly team meetings, and bi-monthly team supervision sessions.
Mildmay is a bespoke clinical environment, containing the clinical skills and specialisms of a rehabilitation hospital but offering a smaller, recovery-focused dedicated space, bolstered by our multidisciplinary team who demonstrate a strong understanding of the psychological needs of this client group.
Mildmay has a clinical team that ensures that the psychological support delivered is evidence-based, of high quality and psychologically informed. The unique composition of the Mildmay clinical team, including a Consultant Liaison Psychiatrist, experienced Clinical Psychologist, Substance Misuse Recovery Worker as well as registered mental health nurses give our staff a strong grounding in mental health and informs the psychologically minded environment in which we practise. Mildmay’s psychiatrist and clinical psychologist provide neuropsychological and psychiatric assessment, day-to-day input and guidance, and supervision to the wider team.
Evidence suggests that individuals who have experienced ongoing and sustained trauma frequently have higher rates of attrition. All staff will be trained in trauma-informed care, equipping them with an enhanced understanding of how experiences of trauma link to maladjusted emotional, cognitive and behavioural patterns and ineffective and destructive coping strategies.
Interventions will be underpinned by theoretical frameworks, such as social learning and cognitive theories, which form an integral component of treatment within an integrated care framework for individuals who misuse substances. Interventions will incorporate Cognitive Behavioural Therapy, Contingency Management, Motivational Enhancement Therapy (MET), Motivational Interviewing (MI), Relapse Prevention, Behavioural Activation, drug-specific interventions and self-help. The programme will be overseen by a Clinical Psychologist, with support from the Consultant Psychiatrist. The drug and alcohol Substance Misuse Recovery Worker will work with both the clients and other staff to ensure that the programme can be delivered by our experienced staff, and supported by volunteers.
Mildmay as a charity has social value embedded into its ethos, with origins and a strong history of supporting and empowering marginalised people. Mildmay was initially established in the 1860s as a project to support local homeless and vulnerable populations and later evolved into an independent mission hospital. Although it has been part of the NHS since 1948, it remains enormously committed to its original values, focussing on empowerment, having a positive impact on communities and celebrating life in all its fullness for everyone in Mildmay’s care. Mildmay has demonstrated these values by being at the forefront of HIV care since the 1980s and since April 2020 by diversifying its services to deliver step-down care to people who are homeless.
Our model, experience and expertise mean we will contribute to economic, social and environmental wellbeing across London
Mildmay’s existing step-down homeless pathway is the first of its kind in London, and has demonstrated innovation as well as facilitated a practical response to the Covid-19 pan-demic. Holistic and person-centred, the pathway aims to support patients with appropriate housing, linking patients with relevant community support services and external partners, as well as delivering medical, nursing and therapy input. The new post-detox homeless pathway will build upon this. We have a full-time experienced Housing Officer on site and discharge planning commences on admission
We empower patients to have a voice, for example by completing patient surveys and giving feedback in relation to all aspects of the care experience
We share positive recovery stories and support/leading anti-stigma campaigns, for example in relation to homelessness, addiction and HIV. We participate in community events raising awareness of key issues
We address health inequalities, developing person-centred care plans ensuring that there is appropriate support at each stage. We encourage patients to be involved in their care planning and discharge planning
We encourage patients to involve their families and loved ones with their care if appropriate, facilitating on-site visits, whilst ensuring that national Covid restrictions are not breached. We offer practical support and advice, and refer families on to external organisa-tions for ongoing assistance where necessary
Mildmay’s multi-denominational and multi-faith chaplaincy team offer patients spiritual support, linking patients in with places of worship and ongoing support where necessary
Our Dietician and her students have extensively researched a range of facilities (day cen-tres, hairdressers, legal advice, food services and many other types of services) available to patients who are homeless within several London boroughs, producing comprehensive in-formation leaflets for patients
Our meal service is tailor-made, fresh and cooked on site, incorporating a wide range of cultures, individual preferences and dietary needs e.g. we are able to provide vegetarian, vegan, Halal, Kosher, gluten free meals and provide appropriate healthy options for pa-tients with allergies and food intolerances as well as patients with swallowing difficulties
We provide a range of clothes and toiletries to patients when this is required and actively encourage donations from local communities and businesses
Balancing this with infection control guidelines, we aim to reduce waste and recycle wher-ever possible
We provide a peaceful and attractive well-designed garden space, accessible to all patients as well as staff and volunteers, encouraging integration and preventing social isolation
We encourage patients to utilise the gym space, our Physiotherapists assessing and advis-ing patients in relation to their physical fitness
Freeview TV’s, DVD players and WiFi are freely available in patient rooms, encouraging pa-tients to connect with friends and family during their inpatient stay. The WiFi also promotes independence, allowing patients to access external support, housing, complete forms etc
We maintain links with a range of universities across London and beyond, facilitating placements for medical students, nursing students including RMN’s and placements for a wide range of allied health professionals for example Dietetics, Social Work, Occupational Therapy and Physiotherapy. We also provide elective and short-term placements
We recruit newly qualified as well as experienced staff, nurturing staff within a wide range of roles within a supportive and supervised environment
We value and invest in our volunteers, who are a key part of our team. We continue to build upon our existing volunteering programme, and where appropriate, offer past patients the opportunity to volunteer at Mildmay and gain valuable experience within a wide range of areas such as fundraising, chaplaincy, administration, reception, estates and facilities, befriending, horticulture. Many volunteers have, over the years successfully gained paid employment at Mildmay Hospital and elsewhere.