Post-detox Recovery Pathway
Page 2 - clinical and service detail
This page provides further detail about Mildmay's Post-detox Recovery Pathway for commissioners, funders, and healthcare professionals. For referral information and admission criteria, see the main pathway page.
The service
Mildmay provides intermediate rehabilitation beds for people who are sleeping rough or at risk of homelessness, following inpatient substance misuse detoxification or stabilisation. Patients are accommodated in a dedicated section of the ward, in private ensuite rooms, with nursing checks at least every hour.
Care is delivered by Mildmay's full multidisciplinary team throughout each patient's admission, from initial assessment to discharge planning. Each patient's care plan is developed with their active involvement and is tailored to their individual medical, psychological, and social circumstances.
Clinical capabilities
Mildmay's medical, nursing, and therapy teams have direct clinical experience in substance misuse and complex co-morbidity management. Specific capabilities include:
-
Prescribing opiate substitute treatments for patients withdrawing from opiates
-
Safe management of alcohol withdrawal, including prescribing and monitoring for complications
-
Administration of prescribed and controlled substances, with an Accountable Officer in post
-
Smoking cessation support and nicotine replacement therapy
-
Neuropsychological and psychiatric assessment, provided by a Consultant Liaison Psychiatrist and Clinical Psychologist
All clinical practice is evidence-based and compliant with UK clinical management guidelines, NICE guidance, and CQC regulations.
Managing complex co-morbidities
Patients on the Post-detox Recovery pathway frequently present with multiple overlapping conditions. Mildmay's team has direct experience managing:
Physical health:
-
Alcohol-related liver disease and pancreatitis
-
Cardiovascular and respiratory conditions, including COPD
-
Malnutrition
-
Hepatobiliary, musculoskeletal, and neurological complications of disease
-
Korsakoff's syndrome
Mental health:
-
Psychosis, depression, and schizophrenia
-
Neurocognitive impairment
-
Learning disability
-
Drug and alcohol use disorders
Psychosocial and safeguarding:
-
Domestic violence and sexual exploitation
-
Trafficking and modern slavery
-
Complex immigration status
-
Forensic history
-
Financial abuse
Mildmay's size and the resulting proximity between clinical disciplines, supports a level of cross-boundary working not always available in larger settings. Staff have time to build therapeutic relationships and provide support beyond routine clinical care, which reduces the risk of repeat admission.
Therapeutic interventions
A daily programme of individual and group sessions combines health promotion, talking therapies, and holistic activity including art therapy, gym access, and chaplaincy support.
The psychological programme is overseen by a Clinical Psychologist, with input from the Consultant Psychiatrist. Psychological support includes assessment and brief intervention/ coping skills informed by approaches such as CBT and ACT
All staff are trained in trauma-informed care, reflecting the high rates of sustained trauma in this patient group and its established association with poorer treatment outcomes.
Progress is measured using validated outcome tools, with particular attention to recovery capital. Monthly and quarterly data are reported to commissioners. A structured discharge assessment is completed for every patient, with a care plan that includes contact details for all providers involved in their ongoing care.
Collaboration and external partnerships
Mildmay works with a range of statutory and community organisations to ensure continuity of care before, during, and after admission. Current partnerships include:
-
Community substance misuse providers: CGL, Turning Point, WDP, SLAM, and CNWL
-
An SLA with Resolve, providing additional specialist substance misuse and homelessness support
-
Infectious disease, HIV, hepatology, and neurology teams across London
-
Local authority social care teams, community mental health teams, and housing providers
-
Care homes and community psychologists, where patients require social care placements on discharge
Some Mildmay clinical staff hold shared roles with Barts Health NHS Trust and East London NHS Foundation Trust, providing direct access to further specialist input where needed.
Rehabilitation outcomes data is submitted to UKROC (UK Rehabilitation Outcomes Collaborative).