Transitional Care:

from the acute psychiatric unit to the community

Carmen Barnard: Registered Nurse – Discharge Planner

Types of transition:

• hospital to community mental health service

• professional and family-based support systems

• health care team and practitioners

• one community team to another

• a health service to their own/family care

• diagnosis and treatment of a new condition

• All transitions involve change.

• Even positive change can be stressful for the consumers, their

family or friends, or even staff.

• Transitions present times of vulnerability in the process of

treatment and care. Consumers have a greater potential to fall

through the cracks.

But it is not all bad….

A transition may present an opportunity to draw on the

consumer's strengths to continue recovery.

Continuous: The plan needs to take into account not just where a

person is going but where they have been.

Coordinated: Sometimes one service or individual cannot meet

all the needs of an individual.

Collaborative: Active consumer and (where relevant) family

involvement

“a state of well-being in which the individual realises his or her

own abilities, can cope with the normal stresses of life, can work

productively and fruitfully, and is able to make a contribution to

his or her community” (World Health Organization, in Keyes

2007 p 97).

Mental Health

Mental Health and Mental Illness is

everywhere.

A recent review in Australia estimated that 2-3% (about 600,000 people) have a severe mental disorder 4-6% (about 1 million) have a moderate disorder 9-12% (about 2 million people) have a mild disorder

In 2011, mental disorders were responsible for 754 deaths, excluding suicide and dementia, with most deaths due to substance abuse, particularly alcohol People with a mental illness on average die 25 years earlier than the rest of the population. • 30 – 40% due to self harm/suicide. • 60% due to medical conditions.

Body and Mind

General public Bipolar Schizophrenia

Obese 23% 21-49% 45-55%

Smoke 25% 54-68% 50-80%

Metabolic syndrome

- 30-49% 37-63%

Recovery

"a deeply personal, unique process of changing one's attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life, with or without limitations caused by the illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of a mental illness" (Anthony, Cohen, Farkas, & Gagne, 2002, p.31

Recovery focus and self-management

• Essential part of managing a long-term illness

• Ongoing and dynamic

• Involves the person, their family, and community services

• About enabling the person to live with the illness

• Does not have to be disease specific

• Can be about identifying barriers/responding to obstacles

• Meetings with the consumers and family

• Mini WRAP

• Consumers signing consent to referrals

• Discharge planning group

• Discharge brochure

• Social worker

• Feed back forms

• Conversations with consumers and family

• Accommodation needs

• Finances

• Need for additional supports

• Family/family needs

• Capacity to make informed decisions

• Mental Health Act status: voluntary vs

involuntary

• Guardianship

• Ability to dispense own medication:

need for a Webster Pack, community

nurses, etc.

• Oral medication or depot medication

• Need for a medical certificate

• Transport

• Intrastate or interstate discharge

• Follow up appointments

• Treating team recommendations vs

consumer’s wants/needs

• Community Mental Health Service

follow up

• Time/date of discharge

• Supply of medication: full PBS, weeks

supply, daily pick up

• Need for OT referral

• Use of trial leave first

• primary and secondary diagnoses

• physical examination findings

• laboratory results

• procedures/investigations

• complications

• drug allergies

• follow up arrangements

• medical/social issues requiring follow

up

• discharge medication

• reason for hospitalisation

• care, treatment, and services provided

• consumer’s condition at discharge

• information provided to the consumers

and family

• risk assessment at time of discharge

• legal status in terms of the Mental

Health Act

• other services involved

• date next depot medication is due

• how many days worth of medication

supplied

• Used between acute consumers and community mental health teams

• Steps involved:

Emailed to general admin account and discharge planning nurse

This is then emailed to the team’s clinical leader

The form is audited

A record is made of transfer of care forms sent for the month

At the start of each week the discharge nurse emails a list of discharged clients to

the General Manger for the previous week.

Details of forms for each consumers also included in Nurse Unit Manger’s monthly

report

Quality of life

“However it is measured, what we all really want is to live a

satisfying and meaningful life of our own choosing. We want

to work in a job that we enjoy, we want to spend our money

doing things we like, we want to maintain our lifestyles and

the activities that we enjoy, we want to be independent, free

of physical pain and be able to spend time and invest energy

into relationships with friends and people we love. We want

the focus to be on our life and how we live it. “ (Mhpod,

2015)