It is tempting to believe that "more of us is better!", but such an attitude is
in contrast to one the Core Features of AMBIT, which is Scaffolding existing relationships - i.e. building on the existing resiliencies in the clients' existing eco-system so that increasing independence from external agencies is a goal.

The assumption is that in a MAINTENANCE PHASE, contact will be less frequent, and more 'forwards planning' will be in evidence.

It would be hoped that by the time an ENDING PHASE has begun, the likelihood of problems in discharging a young person would already be clearly identified, and that this would be being addressed in the Care Plan.

Many teams working to AMBIT principles might feel that, for those young people and families identified as requiring longer term maintenance/support, the team's energy would be better spent in fulfilling a "shepherding" role - helping such clients to develop sustainable links to core/mainstream/clinic-based services. This will depend on local circumstances: a local team will need to Edit this page to clarify this.

Prevention

Avoidance of colluding (unintentionally) in the creation of a hard-to-discharge client is helped by forwards planning - see In my beginning is my end.

Acceptance

Recognition of the fact that some young people (a small minority, we hope) are very significantly disabled on account of, for instance, neurodevelopmental or traumatic burdens is not only realistic, but also preserves hope in the system by helping to realign expectations with reality.

Networking

Conversations with young people, families, their GP, Social Worker, etc, as well as local Health and Social care commissioners, and other agencies (see Who does what?) will be required to clarify provision for the longer term needs and Care Plan required by such young people.

A Dis-integration grid would be likely to support the aim (one of the Core Features of AMBIT) of Addressing Dis-integration.

A Multi-agency meeting well before any discharge date is critical to ensuring a coherent handover of care.