Continuity of care and support following discharge of SMHS mental health clients

Two woman talking. One woman has her back to the camera.

Research has demonstrated that clients discharged from an acute mental health facility are at an increased risk of deterioration, early readmission and even suicide in the days following discharge.

To reduce the risk of early readmission, formal discharge plans which include follow-up with community services and supports, are developed with South Metropolitan Health Service (SMHS) clients and their support person/s. 

Community follow-up is monitored to ensure that each client receives the essential services they require to assist them in maintaining functional improvement and stability, reducing the risk of early readmission. 

Measuring community follow-up

The Fourth National Mental Health Plan, as agreed to by Australia's Health Ministers, assists in collaboratively identifying priority areas for mental health reform, committing governments to a set of agreed actions.

Priority area 3, which relates to service access, coordination and continuity of care, involves the requirement for rates of post-discharge community care.

Community follow-up is measured by the percentage of separations from a mental health service’s acute inpatient unit(s) for which a community ambulatory service contact, in which the consumer participated, was recorded in the 7 days immediately following that separation.

WA Health describes an acute (specialised mental health) inpatient unit as a service that provides voluntary and involuntary short-term inpatient management and treatment during an acute phase of mental illness, until the person has recovered enough to be treated effectively and safely in the community.

The term ambulatory mental health services is used interchangeably with ‘community services’ and ‘non-admitted mental health services’ to describe mental health services provided to people in the community.

A separation for this measure occurs anytime a client leaves an acute mental health care facility following a planned discharge, or discharge against medical advice.

The rate is calculated by dividing the number of clients followed-up by community services within 7 days of discharge, by the number of patients discharged within the same reference period, which is then multiplied by 100 to give a percentage.

Follow-up of a patient is not restricted to communicating with the patient face to face – it may include telephone consults, video links or other forms of direct communication. For the communication to be included in the calculation, the contact must be relevant to the patient’s clinical condition and not for administrative purposes.

Benchmark rates

WA Health has agreed to a number of strategic priorities for Prevention and Community Care Services in 2015-2020. These priorities include working with primary healthcare providers and carers to deliver integrated and more accessible services to patients with the aim of reducing the occurrence of acute illness and improving patient outcomes.

The agreed benchmark rate for the follow-up of mental health clients in the community following discharge is ≥75%. This aligns with the Fourth National Mental Health Plan and the WA Health Strategic Intent 2015-2020.

The benchmark allows comparisons to be made across national jurisdictions, local health service providers and SMHS mental health services. The results of community follow-up for mental health clients are reported on monthly to enable monitoring and the development of action plans to address any identified issues. 

See how we measure up

The graph below shows the overall community follow-up rate across SMHS hospitals with an acute mental health unit:

  • FHHS – Fremantle Hospital and Health Service
  • FSH – Fiona Stanley Hospital
  • RkPG – Rockingham Peel Group

Figure 1: Percentage of community follow-up within the first 7-days of discharge from an acute mental health unit, March 2017–June 2018

The overall percentage for SMHS of community follow-up within seven days 7-days of discharge from an acute mental health facility has averaged above the benchmark rate of ≥75 per cent at 79.8 per cent for the majority of 2017 and this has continued to be achieved for the first half of 2018 at 76.45 per cent.

What do these figures show?
  • The overall percentage for SMHS of community follow-up within seven days 7-days of discharge from an acute mental health facility has averaged above the benchmark rate of ≥75 per cent at 79.8 per cent for the majority of 2017 and this has continued to be achieved for the first half of 2018 at 76.45 per cent.
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South Metropolitan Health Service