Community Rehabilitation Team Helps 60 People Avoid Hospital Readmission

A specialist community rehabilitation team has successfully supported 60 people with complex mental health conditions to remain out of hospital, including Muhammad Khan, 41, from Oldham, who spent nearly a decade in psychiatric care before his discharge one year ago.

The Pennine Care NHS Foundation Trust team, which supports adults with serious mental health conditions and complex needs, began working with Muhammad in late 2023 after he had spent six years in his most recent hospital stay. Through intensive psychology sessions, weekly meetings with peer support worker David Hill, and support at his supported living accommodation, Muhammad has maintained his recovery outside hospital walls.

“I have a diagnosis of schizophrenia. I was first admitted to hospital when I was 23 and have been in and out of hospital for nearly 20 years,” Muhammad said. “My most recent and longest stay was six years. Some hospital placements weren’t near my family. We couldn’t see each other very often which was hard.”

Muhammad’s experience reflects a broader pattern of hospital readmission that the community rehabilitation team aims to break. “In the past I didn’t have the right support once I was discharged. This led to me relapsing and being readmitted. It was a like a revolving door,” he explained. Since his discharge, Muhammad has written three books, presents a radio show tackling mental health stigma, and won service user of the year in the 2022 Nursing Times Awards.

David Hill, who meets Muhammad weekly, emphasized that hospital care, while sometimes necessary, is not optimal for long-term recovery. “It’s much more expensive to care for someone in hospital. But it’s not about money, it’s about what’s right for patients and their recovery,” he said. “Without the right support this can be overwhelming and lead to a relapse. It’s been a privilege supporting Muhammad’s recovery journey over the last 18 months.”

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