Links not boundaries: service transitions for people growing older with enduring or relapsing mental illness

This document updates Council Report CR110 Caring for People who Enter Old Age with Enduring or Relapsing Mental Illness (‘Graduates’). It has been produced by a working party including representatives from the Faculties of Old Age Psychiatry, General and Community Psychiatry, and Rehabilitation Psychiatry, from the Faculty of Old Age Psychiatry Consumer Group and a mental health nurse.

The report makes a series of recommendations aimed at improving the care of people who are growing old with enduring or relapsing mental illness and who face the possibility of moving between psychiatric services, most commonly from general and community (or rehabilitation) psychiatry to the psychiatry of old age.

The recommendations fall into six main areas:

1. 1. use of transition protocols

2. 2. assessment

3. 3. process of transition

4. 4. care plan

5. 5. monitoring

6. 6. commissioning.

Transition between services can be a difficult and worrying time for service users and their families or carers. Mental health service providers are advised to consider these recommendations, produced after wide debate to which many people have contributed, and to review their policies and procedures in order to improve the experiences of individuals using their service.