Comorbidity treatment service model evaluation

Processes/procedures for referral to and communication with other providers

Page last updated: August 2009

Services were asked to describe discharge planning, such as whether they have written care plans, collaborate with other team members and other services in the community, provide client education about diagnosis and symptom management, or link clients with community supports. All services reported having discharge planning processes and procedures in place. The majority of services (n=15) use formal discharge plans, which are sometimes part of a client's overall care plan. Five services stated that reports, letters or discharge summaries are sent to referring services, GPs, or the courts. Ten repondents indicated that their discharge processes include linking clients with other relevant services. For example, one service reported the following:

We do all of what is listed above. We have a contingency/risk management plan for all clients who may voluntarily discharge themselves against clinical advice. We provide housing, employment, welfare and educational support for all clients who are discharged. We link clients in with other services, educate them about medication, where possible, talk to their carer (if we have consent). On admission (just in case they leave), we give them a 'split kit' and go over it with them, which has every possible referral agency plus condoms, food vouchers etc. Discharged clients may also remain linked in to all services; for example, counselling, medical, psychiatric.
An Indigenous service pointed out that 'these links are tested' before leaving and may start with an initial community interview etc. If a client appears to be going to leave before completion, some form of formal Discharge Plan is still attempted'. A youth service detailed the following discharge processes:

Discharge from withdrawal units–Nursing discharge form which may involve collaboration and referral to other services. Exit summaries which are completed by youth workers are also sent to the referral source. Outreach teams–when a client is approaching 22 years, there is intensive discharge planning which may involve supported referrals to other agencies and would always have a holistic focus (e.g. mental health, housing, harm-reduction). [Name of service] has capacity to see clients as long as needed up to age 22 as long as they have significant treatment goals. This may mean clients have periodical entry and exit points during any one year. Residential rehabilitation–intensive and extensive discharge planning with other involved services and clients' families where possible.
Of the two services that reported informal processes for discharge, one noted that clients are provided with discharge packs which include information about the service 'in the event they will again require our service, along with feedback forms'. The other service advised that 'often clients are required to attend for a set number of appointments. If not, they simply stop attending on their own accord'.