The Process of Discharge Planning

5 4.1 Initial treatment planning

5 4.2 Comprehensive planning

6 4.3 Discharge planning

6 4.4 Post-discharge planning 6

5 The Content of Discharge Plans

7 5.1 Client details

7 5.2 Needs assessment

7 5.3 Service arrangements

9 5.4 Checklist 10

6 Information Systems and Monitoring Patients

4.1 Initial treatment planning :The following discharge planning activities should be reflected
in the initial treatment plan which starts on admission. This is not intended as an exhaustive list
of activities related to discharge planning. It provides guidelines that will be useful in the
planning process.

• Involve patient as much as possible in identification of discharge needs and goals. • Contact
family (where appropriate), significant others, GP and/or community treatment team about
functioning prior to this episode of illness and the pattern of illness. • Identify needs and plan
goals of treatment and support with patient and others significant to him/her. • Formulate
provisional discharge plan.

4.2 Comprehensive planning :The following discharge planning activities should be reflected in
the comprehensive treatment plan.

• Use the initial treatment plan and expand on it. • Continue the maximum possible participation
by the patient and others significant to him/her in the development of the plan. • Perform
individual needs assessment with particular reference to needs on discharge. • Devise plan based
on needs assessment. • Initiate ongoing contact with community-based follow-up services. •
Initiate illness management training including use of medication. Include family/ whänau or
caregiver in education about the disorder and how it affects the patient and his/her family. •
Implement initial steps of discharge plans including patient and key worker visits to possible
community accommodation, patient attending community-based services etc.

4.3 Discharge planning :

At this stage the following planning activities have been undertaken.

• The key worker/case manager for post-discharge care has been identified. • Discharge
preparation as in the comprehensive plan should have been completed. • The various needs of the
patient’s care in the community have been addressed (see initial treatment plan). • An integrated
approach is taken in planning services to meet the patient’s needs. • There is clear
communication of the completed plan to the post-discharge key worker/case manager.

4.4 Post-discharge planning :

Responsibility for planning after discharge depends on the organisation of the follow-up
programme. If ongoing treatment is provided by an agency or individual not associated with the
hospital, that agency assumes the responsibility for continued planning and may include the
hospital staff as appropriate. ‘In summary, specific discharge planning activities are important at
each stage of treatment planning, including the initial and comprehensive plans that are a part of
inpatient treatment. Continued monitoring and planning is required as the patient moves into
community-based treatment. Responsibility for ongoing planning after discharge rests with
those providing the treatment’ (Babich and Brown 1991).

5 The Content of Discharge Plans

The content of the ‘discharge plan’ can be summarised into four different components. These
are: • client details • needs assessment • service arrangements • checklist of necessary patient-
related and administrative actions to be taken to ensure a well-managed discharge.

5.1 Client details :

This information can be taken from the mental health information system and includes:

• name • DOB • NHI identifier • legal status • summary of hospital admissions • current
residential address • name of key worker • name of clinician (if different from key worker) •
record of incident reports (date and reference).

5.2 Needs assessment :

There are a number of tools available for needs assessment. A needs assessment schedule (NAS)
prepared for the Department of Health by the Christchurch School of Medicine was distributed in
1990. A residential rehabilitation assessment format developed for use at Ngawhatu Hospital
from January 1993 is attached as Appendix 1.

An assessment working group has been set up as part of disability support services (DSS)
reform. It is developing protocols for assessment processes for all people with disabilities,
including people with psychiatric disabilities. These protocols will be finalised by 30 June 1994.

The needs assessment process used for discharge planning should ensure the following areas are
addressed.

1 Strengths and aspirations:

Needs assessments often tend to be lists of handicaps and disabilities. Identifying the strengths
and aspirations of the patient and assisting him/her to formulate realistic goals is critical to the
success of rehabilitation.

2 Clinical needs :

An individual patient has particular needs for appropriate treatment which depend on the nature
of the condition(s) from which he/she suffers. These should be identified and procedures for
meeting them specified.

The clinical needs can be compiled from case notes or a case summary and from the initial and
comprehensive treatment plans. These needs include:

• diagnosis and clinical problem list • precipitants to illness • pre-illness level of functioning •
treatment history, and response to treatment • capacity and willingness of the patient to co-
operate in the safe administration of treatment • willingness of the patient to be involved in
discharge planning • identification of factors that may predispose to relapse of illness • family
understanding of illness and treatment • family needs related to illness • specification of
recommended further treatment and monitoring procedures • identification of the procedural
requirements where compulsory treatment is undertaken pursuant to the Mental Health
(Compulsory Assessment and Treatment) Act 1992 • education of the patient and caregivers with
regard to treatment, including side effects of treatment • identification of risk factors which
predispose the patient to distress, relapse of illness or behaviour which may endanger him/her or
the public • specification of procedures to deal with risk factors and adverse incidents •
specification of dates for clinical reviews.

3 Generic needs:

All patients who move into community living situations have basic needs that should be
identified using needs assessment and they should be considered in developing discharge plans.
(a) Living arrangements:

• Living situation prior to hospitalisation. • Adequacy and the availability for return to living
situation. • Housing (and type). • Capacity to manage daily living activities. • Supervision,
support (family, health professional, other). • Encouragement and skill development for
achieving an adequate level of independent functioning.

(b) Economic needs • Education or employment opportunities. • Work skills development. •

(c) Personal health care • Timely and affordable access to primary health care services and
specialist health professionals as required. • Access to dental examinations and treatment.

(d) Social, cultural and spiritual needs • Opportunities for meaningful social, cultural and
religious activities including leisure activities. • Social skills and leisure skills development
programmes. • Opportunities to participate in self-help groups and survivor networks. •
Facilitation of family, whänau and iwi support.

5.3 Service arrangements:

For each area of identified need there should be a statement about:

• the service to be provided, or • the action to be taken.

A general service plan is a way of recording this information. An example of a plan currently in
use at Ngawhatu Hospital is attached as Appendix 2.

The complexity of discharge planning in the case of persons with multiple or complex
disabilities makes the co-ordination of necessary services a critical issue. This is best managed
by a suitably skilled key worker/case manager who would ideally be from a community mental
health team.

Good case management will include such factors as:

• treatment of co-morbid conditions such as alcohol and drug abuse, which may lead to the
patient being at risk • active follow-up when scheduled appointments are missed or when even
minor adverse incidents are reported• efficient information systems that can identify patients
currently at risk (eg, patients of concern, patient alert). Records should be readily available.

5.4 Checklist

A predischarge or discharge checklist is a useful way of ensuring that all necessary actions are
taken to make arrangements for the patient’s discharge, notify all concerned parties and to ensure
that patient information systems and hospital administrative procedures are updated.
Discharge Planning

Q. What are the requirements for discharge planning related to persons in mental health
facilities?

Federal Conditions of Participation govern hospital responsibilities for discharge planning. In

394.459(11), F.S. Right To Participate In Treatment And Discharge Planning.-

The patient shall have the opportunity to participate in treatment and discharge planning and
shall be notified in writing of his or her right, upon discharge from the facility, to seek treatment
from the professional or agency of the patient's choice.

65E-5.1303, FAC Discharge from Receiving and Treatment Facilities.

(1) Before discharging a person who has been admitted to a facility, the person shall be
encouraged to actively participate in treatment and discharge planning activities and shall be
notified in writing of his or her right to seek treatment from the professional or agency of the
person’s choice and the person shall be assisted in making appropriate discharge plans. The
person shall be advised that, pursuant to Section 394.460, F.S., no professional is required to
accept persons for psychiatric treatment. (2) Discharge planning shall include and document
consideration of the following: (a) The person’s transportation resources; (b) The person’s access
to stable living arrangements; (c) How assistance in securing needed living arrangements or
shelter will be provided to individuals who are at risk of re- admission within the next 3 weeks
due to homelessness or transient status and prior to discharge shall request a commitment from a
shelter provider that assistance will be rendered; (d) Assistance in obtaining a timely aftercare
appointment for needed services, including continuation of prescribed psychotropic medications.
Aftercare appointments for psychotropic medication and case management shall be requested to
occur not later than 7 days after the expected date of discharge; if the discharge is delayed, the
facility will notify the aftercare provider. The facility shall coordinate with the aftercare service
provider and shall document the aftercare planning; (e) To ensure a person’s safety and provide
continuity of essential psychotropic medications, such prescribed psychotropic medications,
prescriptions, or multiple partial prescriptions for psychotropic medications, or a combination
thereof, shall be provided to a person when discharged to cover the intervening days until the
first scheduled psychotropic medication aftercare appointment, or for a period of up to 21
calendar days, whichever occurs first. Discharge planning shall address the availability of and
access to prescribed psychotropic medications in the community; (f) The person shall be
provided education and written information about his or her illness and psychotropic medications
including other prescribed and over-thecounter medications, the common side-effects of any
medications prescribed and any adverse clinically significant drug-to-drug interactions common
between that medication and other commonly available prescribed and over-the-counter
medications; (g) The person shall be provided contact and program information about and
referral to any community-based peer support services in the community; (h) The person shall be
provided contact and program information about and referral to any needed community
resources; (i) Referral to substance abuse treatment programs, trauma or abuse recovery focused
programs, or other self-help groups, if indicated by assessments; and (j) The person shall be
provided information about advance directives, including how to prepare and use the advance
directives.

Q. What are Baker Act receiving facilities required to do in preparing a person for
discharge?

Baker Act receiving facilities are required, for all persons being discharged, to consider the
person’s transportation resources; access to stable housing; access to medications and access to
an aftercare appointment. They are required to give persons education and written information
about their illness and their psychotropic medications including other prescribed and over-the-
counter medications, the common side-effects of any medications prescribed and any adverse
clinically significant drug-to-drug interactions common between that medication and other
commonly available prescribed and overthe-counter medications, as well as information about
and referral to any communitybased peer support services in the community; information about
and referral to any needed community resources; and referral to substance abuse treatment
programs, trauma or abuse recovery focused programs, or other self-help groups, if indicated by
assessments