Post Discharge Support Program

For health professionals

The post discharge support team may provide at least three post-discharge follow-up contacts within the first 28 days of discharge from the mental health inpatient unit. Contacts will be made by telephone and will also include a community/home visit from the post discharge peer support workforce, unless declined by the patient or deemed unsafe to complete.

Eligibility for peer support includes:

• people experiencing a severe mental illness and
• identified as high risk of readmission
• people with a potential and/or history of protracted length of stay or
• people who would benefit from additional support or
• patients being discharged to new or insecure accommodation.

The peer support program may provide support in:

• assisting patients to develop goals for recovery, to participate in creating their treatment plan and/or care plans while on the ward
• assisting patients to create their own advance statement and nominated person upon discharge from an acute mental health inpatient unit
• assisting patients to complete tasks related to discharge while still an inpatient in consultation with the community case management team where applicable.

Procedural information

Referral to the Post Discharge Support Program can be made through discussion in ward rounds and other formal clinical meetings (including family meetings).

Referrals could take place at discharge planning meetings but, ideally, the referral will be received prior to formal discharge planning, as the post discharge support team should be effective partners in planning discharges.

The referral email or discussion must include the client’s details, potential discharge date and the reason for referral and perceived benefits to the client or carer of the referral.

If family or carer is being referred, the referral must include the name and relationship of the carer and their contact details.

Referrals for the post discharge support program can be made by any mental health professional involved in the patient’s care or the post discharge support team. This includes community teams who are working with the patient on admission.

Clients and/or carers and significant others suitable for referral to the post discharge support program should be identified as early as possible enabling the post discharge support team to assist with planning the transition from the inpatient unit.

The senior clinician in the post discharge support team will prioritise referrals based on need and the eligibility criteria above. This enables the senior clinician to effectively manage the team’s workload.

What/when you should refer to us

Eligibility for peer support includes:

• people experiencing a severe mental illness and
• patients identified as being at a high risk of readmission
• people with a potential and/or history of protracted length of stay or
• people who would benefit from additional support or
• patients being discharged to new or insecure accommodation.

Additional contact details

Clare Moore Building
Werribee Mercy Mental Health Inpatient Unit
300 Princes Highway
Werribee Vic 3030
Phone: 03 8754 3560
Fax: 03 8754 3570