Discharge Planning 101

image credit tristatehospital.org

When discharging a client from one mental health service to the next there are basic rules to follow. I know it can be messy and I will attempt to address this as well. Whether it be higher level of care like outpatient to inpatient, a partial hospital to an outpatient clinic, our from one mental health clinic to another; please try to do the following..

1) Discharge planning should start the moment the treatment plan is developed. I am not just talking about checking boxes of where they should go; really take the time to research where the client will go. Make phone calls,  schedule a visit, do your research. The client and family should be active participants in this process as well.  Things can get complicated but try your best to make the “discharge plan” in a treatment plan is realistic, attainable, and specific.

You are almost always in a position to be proactive as possible, but I know things happen at the last minute. Things like court orders and unexpected discharges happen.

2) Get the basics and as much info as humanly possible to the next provider. At least get demographics, significant alerts, and medication reconciliation (list of medications prescribed sign by the MD). This would be the bare minimum. If it looks like the client is going to run out of medication please ensure there is plan for prescriptions to continue until the next provider can pick it up.

On top of the bare minimum there needs to the initial psychosocial, psychiatric evaluation and treatment plan. An added bonus would be the last 4 therapy notes, last psychiatric note, and psychological testing (if done). Any specialized risk or medical assessments should accompany the transfer as well. Some organizations have a check list before acceptance. This can cause delays but sometimes makes for clear communication.

3) Follow through– If you don’t hear anything after a certain amount of time (depending on the level of transfer) give a call after the referral has been complete. If there is a wait list, give updates to the next provider as far as progress.  Be honest and don’t hold back information. It will only hurt the client in the end.

4) Don’t Dump and Run- I understand that there are ridiculous productivity demands but a 10 minute follow up phone call to family and/or the next provider can make all the difference. I believe a face to face transfer meeting is best practice.

Please try your best to follow these rules. If you want to add some suggestions please do. Please try to be positive and focus on successes…

Sean 🙂




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