National practice standards for the mental health workforce 2013

Standard 8: Transitions in care

Page last updated: November 2013

On exit from a service or transfer of care, people are actively supported by mental health practitioners through a timely, relevant and structured handover, in order to maximise optimal outcomes and promote wellness.

The mental health practitioner:

  1. Prepares people and families/carers for exit from the service or transfer of care
  2. Adheres to policies and procedures regarding transfer of care, with a focus on recovery and health promotion
  3. Regularly reviews the transfer of care plan with the person and family/carers in respect to clinical status, the person’s and family or carer’s wishes and estimated date of transfer
  4. Assesses the person, completes relevant outcome measures and obtains feedback from the person and family to support decision making related to planning for transfer of care
  5. Clearly identifies and follows through on roles and responsibilities in partnership or shared care arrangements, including engaging in assertive follow-up
  6. Provides the person and, with the person’s informed consent, their family/carer and relevant agencies with information to support transfer of care
  7. Provides clear documentation using designated forms and documents in a timely manner to the service where the person is being transitioned or referred, and consistent with privacy requirements