A Model for Success: P4D's Impact on Community Mental Health
Imagine the vulnerability of leaving a hospital setting, only to face the complexities of community life feeling unprepared. This is a reality many have experienced. However, the 'Prep 4 Discharge' (P4D) programme is changing that narrative. Students at the Recovery and Wellbeing College are now stepping into their communities with confidence and preparedness, witnessing life-altering outcomes. Shaping Change sought to understand the heart of this initiative, highlighting the powerful change being driven by colleagues within CAVUHB.
The transition from inpatient mental health care to community living can be fraught with anxiety and uncertainty. Recognising this, the Recovery College at Cardiff and Vale UHB has pioneered a transformative P4D programme, designed to empower individuals and bridge the gap between hospital and home. This initiative, born from a deep understanding of lived experience and co-production, is improving the discharge process. So far, they have seen a significant improvement in adult mental health readmission rates with graduates of P4D at 7.4% when other Health Boards are experiencing 33% rate.
Traditionally, discharge planning often focused on logistical arrangements, leaving individuals feeling unprepared for the emotional and practical challenges of recovery. The P4D programme, however, takes a holistic approach, addressing the true concerns of those leaving inpatient care.
P4D has seen a significant improvement in adult mental health readmission rates with graduates of P4D at 7.4% when other Health Boards are experiencing 33% rate.
Co-production at its heart
The programme's foundation lies in co-production, bringing together individuals with lived experience, practitioners, and service providers. This collaborative approach ensures that the curriculum reflects the genuine needs and concerns of those transitioning from hospital. Andrew Sims, from the Recovery College, highlights how the programme stemmed from conversations with individuals who had experienced readmissions and delayed discharges. By asking, "Why were you readmitted?" and "What are you worried about when you leave?" uncovered critical gaps in support and understanding.
Addressing real-world concerns
The P4D curriculum tackles practical issues often overlooked. Participants learn about navigating community mental health teams, understanding their care plans, and accessing crucial resources. For instance, the programme addresses the common misconception that community teams provide 24/7 support, helping individuals develop realistic expectations and alternative coping strategies. It also emphasises the importance of understanding available resources like Dewis Cymru, a comprehensive directory of mental health support services.
“Our Preparing for Discharge programme has made a meaningful difference to both students and services. Co-produced and co-delivered by people with lived experience, it supports individuals on inpatient wards to feel more prepared, informed, and empowered about their discharge journey. Students have told us the course helps reduce anxiety around leaving hospital, builds confidence, and offers a sense of hope by hearing from peers who’ve been through similar experiences. For services, it complements clinical planning by offering an additional layer of emotional and practical support rooted in real-life experience. It’s a great example of how lived experience can enhance recovery-focused care and improve transitions from hospital to home.””
Empowering individuals through skill development
The programme focuses on developing essential skills for independent living and wellbeing. Students learn to identify early warning signs of distress, manage their own wellbeing using tools like "traffic light triage," and build their recovery capital.
Furthermore, the programme promotes a shift from "risk-focused" to "safety-focused" language, giving students a sense of empowerment and agency.
The ‘Wellness Passport’
A key component of the P4D programme is the development of a ‘Wellness Passport’, a personalised resource containing essential information and strategies for maintaining wellbeing post-discharge. This passport might include a map of local resources, personal coping strategies, and a plan for building social connections. The concept of the ‘Wellness Passport’ is to facilitate that similar to an actual passport where the purpose is to ‘allow the bearer to pass freely without let or hindrance.’
“It’s such a privilege to work in this way with practitioners from different disciplines who are so deeply committed to the personal recovery of their patients. And it’s such a relief to hear people who access inpatient services leaving hospital saying that, regardless of what their move-on from hospital looks like, they feel prepared for their what’s next. To feel empowered and prepared for what’s next, with a confidence about where to access the right support in the future to stay well, is a best hope realised for wellness.”
Building lives in the community
The programme also addresses the challenges of maintaining and rebuilding relationships. Participants learn how to communicate their needs effectively, manage boundary changes, and build supportive networks. This focus on relationship-centered care acknowledges the importance of social connections in the recovery journey.
Feedback from P4D graduates consistently highlights the programme's transformative impact. Individuals report feeling more confident, prepared, and empowered to manage their mental health in the community. As Rachel Wheeler, Recovery and Wellbeing College Manager, notes, the program brings together essential information and resources in one accessible place, creating a vital support structure.
““This project provides a perfect example of why co-production is critical for service users, clinical teams and the wider health system. It delivers benefits to service users, improving outcomes and experience so that they feel empowered and prepared for the next step in their journey after hospital stay; for clinical teams it enhances their offer of support and provides a holistic approach to discharge planning; and it improves flow for the wider health system so that service users receive the right care from the right person at the right time.””