Riley’s Story: Case Study
A non-binary person smiles.
Long-Term Hospital Stay to Independent Living in the Community
Before joining Supported Living provider, Abacus Care & Support, Riley spent three years in hospital due to severe mental ill-health – largely triggered by traumatic experiences and a challenging upbringing. As Riley neared institutional discharge, the specialists on their ward held two realities in tension: The longer Riley spent in hospital, the more ingrained their self-critical beliefs and dependence on services would become. But in the community, away from the safety-net of hospital, Riley would likely express distress through behaviour that put themself and others at risk. The benefit of community re-integration would only be realised through positive-risk-taking and the resilient collaboration of Riley, Abacus and the local services who support them.
A New Way of Living
“We spoke a lot about whether Abacus could give Riley the support they needed.” reflects Director of Abacus Care & Support, Nana Banton. “Riley deserved to be part of their community again, but in many ways, hospital had been a home to them. Getting used to life in the community – and adjusting to its expectations – would take time.”
Supported Living offered Riley a new living environment, and the kind of freedom and independence that weren’t possible in hospital.
“I appreciated that some parts of my discharge [were taken] slow[ly], however there was a lack of communication at times which I found difficult.” Riley explains, “I found the change of environment challenging. I was used to a controlled environment of routine [and] restriction.”
Following a ‘high risk discharge’, early and meaningful intervention from support services is crucial. Effective support can help interrupt the cycle of placement breakdown and hospital re-admission. Despite the increase in Riley’s risky behaviours, it was crucial that the professionals supporting them didn’t give up. They went to great lengths to keep Riley out of hospital and safe within the community.
Partnership and Tailored Support
Riley’s multi-disciplinary-team (MDT) comprised representatives from local support services:
Care Provider – Abacus Care & Support
Community Mental Health professionals – Hertfordshire Partnership University NHS Foundation Trust (HPFT)
Emergency Services – Hertfordshire Police and East of England Ambulance Service
Riley’s MDT worked collaboratively to support Riley and reduce their reliance on crisis intervention.
“The level of crisis Riley was experiencing not only impacted them, but also became extremely challenging and resource-intensive for services.” says Amy Thorp, Coordinator for Hertfordshire Mental Health Policing Team. “As an MDT, collaborating across professional services allowed us to provide Riley with unified support, and to support one another professionally.”
Their breadth of skill and experience enabled the MDT to offer Riley highly tailored support, crucially informed by what they (and their advocates) said about the challenges they were experiencing.
Amy continues, “All services within the MDT went above and beyond, each playing their part in de-escalating negative situations and guiding Riley towards ongoing positive change.”
Out of hospital, Hertfordshire Police spent 100+ hours dealing with Riley in the community. Many times, the severity of their crisis meant that Riley was sectioned under the Mental Health Act.
Sergeant Alan Clarke adds, “We needed a joint approach to turn things around. In holding Riley’s service reliance to account, we had to maintain firm boundaries whilst being sympathetic to their needs.”
One professional support tool used was a police passport, personalised to help officers understand Riley’s needs. This was informed by Riley’s thoughts on what would help them during police incidents.
“It took time to effectively tailor our interactions with Riley,” continues Alan. “But we began to see positive change as a result. It’s now been months since Riley’s needed police services! Taking a personalised approach has been incredibly effective. We’re glad we stuck with it.”
Emily Suffling, paramedic with East of England Ambulance Service, adds: “We’ve gone from struggling with how best to support Riley through frequent crisis calls, to a significant stretch of time where they’ve not needed our services at all. It’s an incredible result.”
Exceeding Expectations
A year ago, Riley struggled to envisage spending even one night away from hospital. Then, when life in the community was at its toughest, it was understandable that professionals struggled to see how Riley could avoid hospital re-admission.
Florence Bishop, Community Mental Health Nurse, reiterated to her MDT colleagues the need for perseverance. “My clinical experience led me to expect an intense period of make-or-break testing. But I didn’t believe being re-hospitalised would help Riley, long-term. Giving up just wasn’t an option.”
The breakthrough that followed was significant. Florence puts Riley’s massive achievement into perspective. “When we ask someone like Riley, who has been in hospital since adolescence, to: live somewhere new, behave by society’s standards, be a self-sufficient adult, do this, don’t do that... it’s an incredibly tall order. We expect them to do all sorts of things – which haven’t been expected of them before – within a transition period that is typically much shorter than the time they’ve spent in hospital. It wasn’t easy, but Riley’s really risen to the challenge and worked hard to get to this point.”
What Have We Learned?
Creative solutions are possible with supportive collaboration. Recognising each service’s unique concerns, professional limitations, and expertise illuminated our strengths and enabled us to deliver creative solutions. Because we reached a collaborative understanding, our approach could be consistent, even in challenging situations.
Tolerating risk is essential. We must do what we can to mitigate risk, but we can’t eliminate it entirely. It’s easy for the anxiety we feel as professionals to interfere with an individual’s progress. Riley had to be able to emerge from their risky behaviour knowing they’d not been abandoned by their support network – rather than be restricted from making any mistakes.
Resilience drives progress. Although there will always be problems that feel insurmountable, the greater problem is losing hope that a solution can be found. Time and again we had to choose to dig deep and believe that change was possible. Because of this our skilled, resourced and collaborative MDT were able to maintain patience and resilience in the face of adversity.
A Brighter Future
Throughout Riley’s transition from long-term hospital care to Supported Living, commitment and collaboration has brought about real change, even in the toughest circumstances. And although the frequency of Riley’s MDT meetings is now decreasing, the team are dedicated to responding accordingly to any fluctuations in their recovery journey.
Reflecting back, Riley says: “The most difficult part was not knowing my place in the world - I didn’t know what my identity was. I felt my identity was ‘a patient’. I had to find myself.”
Supported by Abacus and their MDT, Riley is continuing their journey of self-discovery. They’re learning to make good choices, face challenges head on, and take responsibility for their actions. Riley’s even got a job as an expert-by-experience at NHS UK, and has recently enrolled in a foundation paramedic science course at college – a testament to how far they’ve come, and the brighter future ahead.