GuidelinesThe intent of this standard is to ensure that mental health services (MHS) have policy and procedures on how to assist consumers when they exit the service and that consumers are provided with sufficient information on how to re-enter the service if / and / or when required.
Access and information on services (Criteria 10.6.1, 10.6.2)The consumer is given formal introductions to various community agencies. Information provided might be in the form of a booklet available in a language understood by the consumer and carers or verbal information relayed with the assistance of appropriately trained interpreters. Any information or introductions are given before the consumer exits the service.
Development of exit plans (Criteria 10.6.3, 10.6.4)The exit plan should identify:
- measurement of change in health status
- satisfaction with service
- perception of quality of life
- review of goals in individual treatment
- care and recovery plan
- peer review
- case discussion
- methods used to evaluate outcomes, including the consumer's preferred evaluation.
Top of pageConsumers and their families/carers should be helped to identify early warning signs of a relapse. Symptoms of pending relapse, sometimes called 'relapse signatures', and an accompanying relapse management plan, which includes the accessible crisis services, should be included in the exit plan.
Information in the exit plan should include:
- the preferred health care provider for example the general practitioner or private psychiatrist
- the earliest possible involvement of the consumer's nominated service provider and arrangements for ongoing follow-up
- community resources likely to be needed
- other people likely to be involved
- other details identified by the consumer and/or carers
- preferred method of evaluating outcomes for the consumer
- details of follow-up arrangements with the consumer
- plans for identification of early warning signs of relapse
- information on how to re-enter the MHS
- a clear point of contact in the MHS regarding the most recent episode of treatment and/or support
- shared care arrangements with GPs, private psychiatrists and non-government organisations if applicable.
Re-entering the service (Criteria 10.6.5, 10.6.6, 10.6.7)At the time of discharge any continuing arrangements for treatment and support should be reviewed by the MHS.
To help in the delivery of care in accordance with the discharge/exit plan in shared care arrangements, for example with a GP, information on the consumer should be provided promptly and include:
- treatment, medication, physical health and any pathology results
- requirements/recommendations for the GP in future treatment of the consumer
- process of returning care to the MHS provider in the case of relapse
- contact information of the person responsible.
Follow-up of consumers (Criterion 10.6.8)For the purposes of criterion 10.6.8 discharge is defined as discharge from an inpatient unit or discharge from an episode of care. The criterion does not apply to final discharge of the consumer from the mental health service.
Consumers flagged for follow-up are identified by a risk assessment performed before exiting the service.
There is a clear and documented follow-up process, which identifies the responsible agency, carer and crisis service for the period following the consumer's exit from the service.
Suggested evidenceEvidence that may be provided for this standard includes:
- exit plans showing evidence of relapse management
- shared care arrangements
- evidence of risk assessments and follow-up
- dissemination of information to primary health care providers
- policies and procedures:
- development of exit plans
- exit and re-entry
- follow-up procedures.