DISCHARGE FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES
CPM.M5.17
CLINICAL PRACTICE
MANUAL
PURPOSE
It is the Bay of Plenty District Health Board (BOPDHB) Mental Health & Addiction Service’s
(MH&AS) policy intent that service users of the MH&AS will be assisted to plan for their
discharge from Inpatient Services or exit from the service to ensure appropriate and effective
ongoing follow-up is available if required.
OBJECTIVE
To ensure the safe and appropriate discharge of patients.
To identify and manage risks related to discharge.
To encourage co-ordination of the discharge process using multidisciplinary services as
required.
To encourage effective communication between staff, the client and their family /
whanau.
To reduce the risk of unplanned, re-admissions.
To ensure an appropriate length of stay for inpatients.
STANDARDS TO BE MET
1. Discharge Criteria
1.1 Discharge from a MH&AS may occur when either:
a) The assessed needs of the consumer and goals identified during the
assessment and treatment process have been achieved.
b) The assessed needs of the service user are unable to be appropriately met by
the treating service or are better met by an alternative service provider.
c) The service user has no contact with the service, has not responded to two (2)
attempts to engage with the service and a decision based on multi-disciplinary
team (MDT) discussion and feedback from case manager has indicated that no
risk issues have been identified (except patients subject to the Mental Health
Act).
d) The service user “self-discharges” by negotiation or against medical advice;
(except patients subject to the Mental Health Act). or,
e) The service user moves out of the catchment area.
2. Discharge Planning
2.1 All service users who receive MH&AS will have a discharge plan.
2.2 The discharge plan is commenced during entry to the service and developed
during assessment, delivery of care and review of care.
2.3 Details that may be included in a service user’s discharge plan are as follows (but
not limited to):
a) Preferred ongoing health provider (e.g. GP, Iwi health provider)
b) Community resources likely to be required or of benefit to the service users
recovery / ongoing care
c) Other people likely to be involved
d) Other details as identified by the person who receives the service and their
family/whanau.
Issue Date:
Sep 2015
Page 1 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
DISCHARGE FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES
CPM.M5.17
CLINICAL PRACTICE
MANUAL
2.4 All service users will have an allocated staff member responsible for discharge
planning who will ensure that prior to discharge;
a) A documented multidisciplinary review of the service user’s treatment occurs.
b) The discharge plan is developed collaboratively with the service user and
family / whanau / caregivers (where the service user’s consent is given), who
will have access to a copy.
c) The discharge plan will identify and manage risks associated with the discharge
including expressed concerns of the family / whanau. Evidence of review will be
documented in the clinical notes.
d) Arrangements are satisfactory to the service user, their family/whanau and to
the other providers prior to their discharge
e) Findings from needs assessment, cultural assessment or drug and alcohol
assessment are integrated into the discharge plan, and have been documented
in the clinical notes.
f) Assistance is provided to develop a relapse prevention plan (person centred
care plan for MHSOP in- patients with cognitive impairment) that identifies early
detection or warning signs of a relapse and the appropriate action to take and
staff/services to contact. See
Relapse Prevention Plan: (Ref: Form MHS RPP)
g) The appropriate Mental Health outcome measures are collected from the
service user as specified i
n policy 2.5.2 protocol 9 Mental Health Outcomes
Information (MH-Smart) Collection
h) Referrals have been completed and that contact has been established with the
service user’s general practitioner or other health care providers.
i) Sufficient health information is shared with the service user’s proposed external
service provider(s) to ensure that service users have access to appropriate,
timely and high quality care that meets their needs and furthers their
recovery/care needs.
j) This information will be forwarded prior to discharge and should include but not
be limited to:
i.
Service User Details (name, age, address, contact details, next of kin)
ii.
Mental health history
iii. Diagnosis and presenting issues
iv. Current medication
v. Risk assessment, treatment and discharge plans
vi. The results of specialist assessment (A&D or Needs assessment)
vii. Any other information as negotiated in a Memorandum of Understanding with
that provider.
2.5 A copy of the electronic discharge summary is provided and explained to the service
user and is sent to the GP within 24 hours of discharge.
3. Standards for Inpatient Discharge Planning
3.1 Ultimate responsibility for the discharge documentation rests with the responsible
SMO who is responsible for the patient's management and includes the monitoring
of the discharge process.
3.2 Where the client is new to the service or when for any other reason there is no case
manager involvement it may be appropriate to appoint an inpatient lead nurse to this
co-ordination role.
3.3 Post admission and pre discharge planning meetings will be coordinated by the
identified lead discharge planning clinician. Those in attendance will include the
patient, close family / whanau, relevant members of MDT (psychiatrist, case
Issue Date:
Sep 2015
Page 2 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
DISCHARGE FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES
CPM.M5.17
CLINICAL PRACTICE
MANUAL
manager, lead nurse etc) and where appropriate support from family / whanau and /
or consumer advisor roles. Other agencies involved (NGO’s, Housing agencies etc)
will also be invited to these meetings as required.
3.4 When it is known that community mental health follow-up will be required, a referral
should be made as soon as practicable so that a case manager can be identified
early in the admission.
3.5 The case manager should maintain enough contact with the ward to ensure that
effective discharge planning takes place (minimum standard one contact per week).
The case manager, lead nurse and other members of the MDT work closely
together throughout the discharge planning process.
3.6 Consumer and Family information packs are to be provided as soon as practicable
on admission and utilised as a working tool throughout the patient’s journey through
the inpatient service.
3.7 A discharge planning checklist will be updated at every juncture of the process. This
will be completed collaboratively with the patient and family / whanau if possible. A
copy will be kept in the patient’s health record and another by the patient to be kept
in their information pack.
3.8 A relapse prevention plan will be completed collaboratively with the patient and their
family / whanau. A copy of this will be kept in the patient’s health record and by the
patient in their information folder. Relapse prevention plan standards are also
detailed i
n CPM.M5.36 Relapse Prevention Plans
3.9 Where it is not practical to hold a discharge planning meeting prior to discharge, a
meeting will be arranged for the earliest possible time following discharge.
3.10 All patients with community mental health case manager involvement will receive a
follow up visit within seven (7) calendar days. If this is not possible the reason must
be clearly documented in the patient’s health record.
3.11 Inpatient Discharge Summaries are completed using the standard BOPDHB
electronic discharge summary template by the Psychiatric Registrar or delegated
House Officer.
3.12 Administration staff will ensure that the completed electronic discharge summary for
the current inpatient episode of care is printed out prior to the record returning to the
community team and:
a) A copy placed in the patient’s health record.
b) A scanned copy emailed to the case manager and psychiatrist
c) A copy mailed to the patient at their discharge address
3.13 Administration staff will ensure that the patient health record is sent to coding within
48 hours of the discharge and returned to the appropriate satellite file storage facility
for access by the community team.
4. Transfer of Care
4.1 Transfer of care procedures between responsible clinicians and DHBs are detailed
i
n policy 6.1.2 protocol 6 Transfer of Care.
5. Discharge Against Medical advice
5.1 When a voluntary service user requests to be discharged contrary to the advice of
the clinician or MDT review, the standards for discharge planning will still be
maintained.
5.2 If discharge is still requested by the service user, the case manager will arrange a
discharge planning meeting with the service user, family / whanau other members
Issue Date:
Sep 2015
Page 3 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
DISCHARGE FROM MENTAL HEALTH &
Protocol
ADDICTION SERVICES
CPM.M5.17
CLINICAL PRACTICE
MANUAL
of the MDT involved in the service user’s care and will document the patient’s health
record as follows
“Discharged against Medical Advice”
5.3 Service users who choose ‘Discharge Against Medical Advice’ wil be given
information at the time of discharge on how to regain entry to the MH&AS.
6. Re-Entry
6.1 Service users and their family / whanau, where appropriate, are given information at
the time of discharge on how to regain entry should they require it, including whom
to contact.
6.2 Al
so see CPM.M5.25 Referral
7. Information Systems
7.1 The designated nurse / case manager / responsible clinician will ensure that the
appropriate MH-SMART outcome measures collected from the service user are
entered into the MH&AS Information System.
7.2 The staff member responsible for the service users discharge planning will ensure
that a Linked Referral is closed as per the MH&AS WebPas User manual (page 38)
7.3 Administration staff / Clinician will ensure that the Primary Referral is closed for
service users who are being discharged from the MH&AS entirely as per the
MH&AS WebPAS User Manual, page 38.
REFERENCES
Guidelines for Discharge Planning for People with Mental Illness. MoH. July 1993.
Health & Disability Service Standards NZS 8134:2008
Mental Health (Compulsory Treatment and Assessment) Act 1992 & Amendments 1999
Mental Health WebPAS Training Manual
Southland District Health Board Mental Health Service Feb –Mar 2001: A Report by the
Health and Disability Commissioner
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board policy 6.5.1 Inpatient Discharge Planning
Bay of Plenty District Health Board policy 6.5.1 protocol 0 Discharge Planning - Inpatient
Standards
Bay of Plenty District Health Board policy 6.1.2 protocol 6 Transfer of Care
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.9
Admission to Acute Inpatient Mental Health
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.25
Referral
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.30
Treatment Plan
Bay of Plenty District Health Board Clinical Practice Manual protocol CPM.M5.36
Relapse Prevention Plans
Issue Date:
Sep 2015
Page 4 of 4
NOTE: The electronic version of
Review Date:
Sep 2018
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Quality & Patient
Authorised by: Medical Director
assumed to be the current version.
Safety Coordinator, MH&AS
