The Assertive Transition Service (ATS) is a collaborative service run by Nottinghamshire NHS, St Andrews Heathcare, Framework and Rethink Mental Illness. The service supports inpatients across the East Midlands as they transition back into their communities and offers practical support to help ensure they don’t return to hospital.  

The ATS, launched in February 2020, covers the East Midlands – including Derbyshire, Lincolnshire, Nottinghamshire, Leicestershire and Northamptonshire. Patients are referred from IMPACT (Improved Pathways and Community Teams), who provide adult secure care, around 6 months before they are due to be discharged. The ATS team will then pay the person a visit to explain the support available, and it is their choice whether to move forward with the service.  

Ellie, a Transition Support Worker, spoke on the importance of the service and explained her role:

“We get the privilege of supporting people as they embark on their journey of discharge into the community. Transition Support Workers are a vital part of the team, providing hands on support, advice and guidance. Supporting and seeing service users flourish, develop their independence, and create the life they want for themselves outside of hospital, is the most beneficial part of being a part of the ATS team.”  

The support that the team provides involves a holistic approach to patient care to ensure all aspects of their life are considered. One useful tool they use is called the Recovery Star which helps to assess progress towards several key outcomes, such as managing mental and physical health, reducing addictive behaviours, living independently, and building positive relationships. The ATS also supports carers, family, and friends to help them understand the processes involved in their loved one’s care and provide resources to support their own needs too. This approach helps to reduce peoples' overall hospital stay and gives them tools to support them in building a happy and independent life. 

The team includes:  

This strength-based approach has proven to be very effective. Helen, who was supported by the ATS service, spoke about the impact it has had on her life:

“I struggled with my past, I was abused as a child. I used to always think they were after me, so being in locked services was safe. I would get gate fever as well - I’d get so far up the path towards discharge, and I used to sabotage it. 

“As part of the transition, we used to go out and have coffee or go into town. They spoke to me about how society had changed, because I thought it was going to be quite scary – I didn’t know what I was coming back out to. They assured me it was a safe area, and they visited me quite a lot once I had moved in. I could always call the office and speak to them if I needed to.