Implementation guidelines for public mental health services and private hospitals

10.6 Exit and re-entry

Page last updated: October 2010

The MHS assists consumers to exit the service and ensures re-entry according to the consumer's needs.

Suggested evidence


The intent of this criterion 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.

The consumer's exit from, follow-up and re-entry to the service is the joint responsibility of the private mental health service, the private psychiatrist and the general practitioner.

In rural and remote settings this responsibility demands involvement of the mental health service, the primary care service or Aboriginal and Torres Strait Islander community controlled organisation, and other relevant providers. This may include general practitioners.

Access and information on services (Criteria 10.6.1, 10.6.2)

The consumer should be given formal introductions to various community agencies. Information provided could be in the form of a booklet in a language understood by the consumer and carer, or verbal information relayed with the assistance of interpreters. Any information or introductions should be given before the consumer leaves the service.

Given the limited services available in some rural and remote settings the MHS must keep an updated list of available services and activities and details of how they can help the consumer. This information should be easily accessible and understandable.

Development of exit plans (Criteria 10.6.3, 10.6.4)

The exit plan should contain details of:
  • the change in the consumer's health status
  • the consumer's satisfaction with the service
  • perception of quality of life
  • a review of the goals in individual treatment, care and recovery plans
  • a peer review
  • case discussion and methods used to evaluate outcomes (including the consumer's preferred evaluation methods).
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Exit plans for child and adolescent and aged consumers need to consider issues specific to their demographic. For example, aged-care consumers transferring to a nursing home on leaving the MHS and exit plans for child and adolescent consumers are not usually discussed at entry to the MHS.

The MHS should help consumers and their families and carers identify early warning signs of a relapse. The exit plan should include details of symptoms of a pending relapse, sometimes called 'relapse signatures' and a relapse management plan.

Information in the exit plan should include details on:
  • 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 required
  • other people likely to be involved
  • the preferred method of evaluating outcomes for the consumer
  • follow-up arrangements with the consumer
  • plans for identifying early warning signs of relapse
  • how to re-enter the MHS
  • a clear point of contact in the MHS regarding the most recent episode of treatment 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 ongoing arrangements for treatment and support should be reviewed by the MHS.

To assist in the delivery of care detailed in the exit plan in shared care arrangements, information on the consumer should be provided in a timely manner and should include details of:
  • treatment, medication, physical health and any pathology results
  • any requirements or recommendations for the GP in future treatment of the consumer
  • the 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.

Due to the relatively high risk of suicide in the first four weeks after discharge and to prevent relapse, the MHS, in conjunction with the treating clinician, is required to follow-up wherever possible within seven days of the consumer being discharged from the service. Consumers flagged for follow-up are identified by a risk assessment performed prior to exiting the service.

There is a clear and documented follow-up process, which identifies the responsible agency and crisis service for the period following the consumer's exit from the service.

Despite the greater likelihood of consumer mobility and remote residence, the MHS is responsible for ensuring timely and comprehensive follow up, regardless of location or circumstances, in collaboration with primary care and community controlled organisations.
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Suggested evidence

Evidence 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 covering:
    • the development of exit plans
    • access
    • exit and re-entry
    • follow-up procedures.