Coming Home Implementation: report from the Working Group on Complex Care and Delayed Discharge

4. Dynamic Support Register

4.1 Purpose of the Register

The purpose of the Dynamic Support Register (referred to as the Register) is ultimately to avoid people with learning disabilities living in hospitals, or in out-of-area placements which they/their family have not chosen. It has been designed to help professionals working with people with learning disabilities to better respond to situations where there is a need for a more intensive level of care management.

It aims to:

• Identify and address risks of admission to hospital or out-of-area placement
• Support the development of local community placements

The Register is a tool that should be key to supporting local planning and decision making. It will be utilised and maintained by each local area, however it will be owned nationally so that there is consistency and uniformity in data recorded across all areas. This should help local areas overcome the challenges in fully articulating the nature of individual needs, care requirements and risk assessments when collaborating across both health and social care. It will improve the visibility of this group of people both at a local strategic level and nationally, and allow local areas to monitor their own progress against reducing delayed discharges and out-of-area placements. It will also embed anticipatory care into practice via proactive and preventative measures, to enhance support when people are most at risk.

The Register will be applicable to adults with learning disabilities who are regarded as having complex support needs. While formally undefined, complex support needs may include those, who in addition to having a learning disability:

• Are also autistic
• Have a mental health diagnosis
• Have a forensic need, and/or who are described as demonstrating behaviour that challenges.

4.2 Who the Register is for

The Register will be used for adults with a learning disability whose support is funded by a Scottish Local Authority or Health Board, who are within one of the following groups:

• Currently admitted to hospital-based assessment and treatment units. This will apply to anyone within these units, whether they are formally regarded as delayed or not. It will apply to those in either NHS or private hospitals, either within Scotland or elsewhere in the UK. Those recently (within the last 6 months) discharged from an assessment and treatment unit will also be included in this group in order to monitor readmission risk. Given that some areas use Mental Health beds when Learning Disability units are full, it will also apply to anyone using an NHS inpatient bed in an inpatient setting.
• Living in an unsuitable/inappropriate out-of-area placement.

This is defined as a placement which the person and/or their family did not choose, and which has been used because of a lack of suitable local resources, or a placement defined as poor quality, or that meets the risk criteria^[10].

This applies to placements either in Scotland or elsewhere in the UK.

It does not apply to those living out-of-area if they/their family have chosen for them to be there and if they/their family approve the placement (unless there are serious, legitimate concerns about the placement raised by the HSCP or others).

• At risk of placement breakdown - current living situation is becoming unsustainable.

This may be for those living within a family setting or those who receive support from a care provider. The individual may be at risk of either admission to hospital or having to move to an out-of-area placement. This may be for any of the following reasons:

• Significant increase in severity and frequency of behaviour that challenges over a sustained period, resulting in service providers or family carers who are no longer able to support the person safely or effectively.
• HSCP concerns about the suitability, stability, or sustainability of a placement (e.g. a young person coming near to the end of their school placement).
• Family carers who are becoming unable to continue caring for their family member, or death/illness of family carers.