Table 2.

NSIC Stoke Mandeville SCI Psychological Health and Wellbeing Matched Care Intervention Pathway (UK Copyright Service 284734611).

Category	Clinical Presentation	Pre-admission outreach and previous mental health (MH)	Psychological therapy contact	MDT Consultation	Referral to specialist service	Keyworker and goal planning	Discharge planning
1 Highly complex	Likely to have previous substantial contact with MH or other services for pre-morbid condition. Recent/active self-harm or risk (which could be imminent) to self or others; chronic mental health difficulties with acute relapse; active issues with addiction; severe interpersonal difficulties/those with high levels of social deprivation which affects patient engagement and safety.	Substantial liaison and admission planning	Substantial and frequent, at times of crisis may be more often than once a week	Substantial and frequent, often once a week Clinical psychologist leads in team risk management/ safeguarding is link for liaison with MH services and team requests consultation in crisis situations	Likely (Ideally referral with regular review)	Clinical psychologist keyworker Goal planning meetings often more frequent including liaison in between	Complex, substantial liaison with community staff pre-discharge Discharge letter written with recommendations and onward referral
2 Complex	May have previous contact with MH/GP services or other services for pre-morbid condition. History and risk (but no active or recent presentation) of self-harm or imminent risk to self or others; and/or chronic mental health difficulties with acute relapse; active issues with addiction; severe interpersonal difficulties. Risk of relapse and/or self-neglect.	Significant liaison pre-admission	Regular direct therapeutic contact, usually weekly	Significant consultation Psychologist actively involved in team risk management/ safeguarding and is link for liaison with MH services can be required to provide consultation in crisis situations. Risk managed through psychological consultation with team and provision of adequate support structure.	Possible (Ideally referral with occasional review)	Clinical psychologist keyworker Goal planning meetings usual intensity, may include support in between	Significant discharge planning and liaison Discharge letter written with recommendations and onward referral
3 Routine intervention	Predominant presentation of symptoms above clinical threshold for depression/anxiety or adjustment And/or above in association with: Previous MH needs intervention by GP or no previous MH needs Other pre-morbid condition such as learning disability or dementia or current co-morbid condition such as TBI which complicates adjustment Cognitive assessment needed and management advice	Not usually required unless significant pre-morbid or co-morbid condition which will could impact on rehabilitation engagement e.g., TBI	Regular contact, usually fortnightly or three weekly	Not usually required or minimum Consultation usually takes place in planned MDT meetings	Not usually required	MDT member most usually keyworker or may be clinical psychologist if interpersonal issues affect adjustment Usual frequency of goal planning meetings	May need onward referral via GP to IAPT or mentoring support Contact and discharge summary on IDR
4 Brief intervention	May have previous MH needs intervention by GP or no previous MH needs Predominant presentation of symptoms below clinical threshold for depression/anxiety or adjustment	Not usually required	Regular contact, but after initial assessment and intervention may be infrequent—fortnightly or three weekly. Time limited 1–3 sessions.	Not usually required	Not usually required	MDT member keyworker Usual frequency of goal planning meetings	May need onward referral via GP to IAPT or mentoring support Contact and discharge summary on IDR