Continuum: Aftercare Shouldn't Be an Afterthought

Problem

Mental health discharge in the UK is a communication breakdown disguised as a process.

Patients leave hospital with discharge letters — often lost in the post, forgotten, or impossible to navigate when in crisis. They don't know where to go, what their medication actually does, or who to contact if they're struggling. So they request re-referral. Every month, up to 3 discharged patients from a single clinic request re-referral. Multiply that across the NHS and it's a system failing at its most critical moment.

Clinicians have zero visibility into what happens after discharge. They don't know if a patient is following the plan, struggling, or about to spiral. Re-referrals come in with no context, forcing them to start from scratch.

The core issue: discharge is treated as a transaction (hand over paperwork, patient leaves) not a transition (begin supported journey home).

Solution

Continuum reimagines discharge as the start of continuous care, not the end of it.

For clinicians: An NHS-guided form at discharge that captures everything patients need: contacts, medication details, safety information, housing arrangements, and their rights. No complex data entry — structured, simple, guided.

For patients: An SMS with a unique link to their personalized aftercare plan. It's on their phone, always accessible, in one place. No app download. No login friction. And crucially: a one-tap "I'm struggling" button that alerts their care team instantly.

For care teams: Real-time visibility into patient crises. Alerts only when needed (not endless notifications). The ability to see who's struggling, respond immediately, and decide next steps — re-referral, signposting, check-in.

How It Works

1. At discharge: Clinician fills out the Continuum form, structured around NHS guidance. Takes 5 minutes.

2. Patient receives SMS: Unique link to their plan. They can open it on any phone, any time.

3. Plan contains:

   • Key contacts (crisis line, GP, community team, etc.)

   • Medication details (what, why, side effects)

   • Safety and emergency contacts

   • Housing/living situation and support available

   • Their rights and next steps

4. Patient in crisis: Taps "I'm struggling." Instant alert to care team.

5. Team responds: Sees the alert in their team view, takes action — calls patient, re-refers them, signposts to crisis support.

Current Implementation

Built with: HTML/CSS/JS frontend, Google Sheets backend (MVP). Mobile-friendly web app. Ready for Twilio (SMS delivery) + Supabase (production database) integration.

Design decisions:

• Mobile-first web interface (patients use phones)

• SMS delivery (no app install barrier, works for everyone)

• One-tap alert (crisis moment = no friction)

• Team dashboard (clinicians see what matters)

• NHS-aligned form (speaks the language of the service)

Challenges & Learnings

Challenge: Building a functional MVP in a tight deadline while learning new integrations (Google Sheets → web, SMS pipeline).

Approach: Prioritized core user flows (clinician → patient → alert → team response) over nice-to-haves. Got the communication loop working first, data persistence second.

Learning: The difference between a "nice idea" and a "solution that clinicians will actually use" is specificity. Every field in the form, every button placement, every team view detail had to answer: "Why would someone do this instead of their current workaround?"

What's Next

1. Production database: Migrate from Google Sheets to Supabase for HIPAA/data security compliance.

2. SMS integration: Wire up Twilio for reliable SMS delivery across UK networks.

3. Care team workflows: Expand team dashboard with response templates, re-referral workflows, and follow-up scheduling.

4. Pilot sites: Partner with 2-3 NHS trusts to test with real users and gather feedback on form fields, alert sensitivity, and contact preferences.

5. Mobile app: Build native iOS/Android apps for both clinicians and patients (optional — web-only works, but native is faster).

6. Global scale: Current scope is UK mental health services; future versions could adapt for other healthcare systems and other regions.

Why This Matters

Discharge is when patients need support most and get it least. Continuum closes that gap by making aftercare visible, accessible, and actionable. It respects the reality that care doesn't stop at the hospital door — it just changes form.

For patients: A lifeline when they're alone and struggling. For clinicians: The data to catch problems early and re-refer fast. For the NHS: A system that actually supports continuity of care.

Aftercare shouldn't be an afterthought.