Quality statement 3: Communication on discharge

Quality statement

People discharged from an inpatient mental health setting have their care plan sent within 24 hours to everyone identified in the plan as involved in their ongoing care.

Rationale

Sharing a person's care plan with people who will be involved in their ongoing care (as agreed by the person and their families or carers, and identified in their care plan) at the point at which they are discharged from inpatient mental health settings helps to make sure agreed plans are received as early as possible, so that they can be carried out and treatment continued. This reduces the risk of avoidable harm to the person, as well as avoidable readmissions.

Quality measures

Structure

a) Evidence of local arrangements to develop care plans that detail who will be involved in providing ongoing care to people discharged from an inpatient mental health setting.

Data source: Local data collection, for example, care planning protocols.

b) Evidence of local arrangements to send within 24 hours, the care plans of people discharged from an inpatient mental health setting to everyone identified in it as involved in their ongoing care.

Data source: Local data collection, for example, hospital discharge protocols.

Process

Proportion of discharges from an inpatient mental health setting where the person's care plan is sent within 24 hours to everyone identified in it as involved in their ongoing care.

Numerator – the number in the denominator in which the person's care plan is sent within 24 hours to everyone identified in it as involved in their ongoing care.

Denominator – the number of discharges from an inpatient mental health setting.

Data source: Local data collection, for example, a review of patient notes.

Outcome

a) Level of satisfaction with support following discharge from inpatient mental health settings.

Data source: Local data collection, for example, local patient surveys.

b) Readmissions to inpatient mental health services within 30 days of discharge.

Data source: Data on unplanned readmissions to mental health services within 30 days of a mental health inpatient discharge in people aged 17 and over are available from the NHS Digital Indicator Portal as part of the clinical commissioning group outcomes indicator set – indicator 3.16.

What the quality statement means for different audiences

Service providers (inpatient mental health services) ensure that staff receive training on how to develop care plans, and how to share them so that people involved in care to receive them as early as possible. They have protocols in place to ensure that plans are developed at the earliest opportunity after admission, and shared in a way that allows quickest receipt following discharge, including for people whose admission lasts less than 7 days.

Healthcare practitioners (mental health practitioners) work with people admitted to an inpatient mental health setting to identify people who will be involved in the person's care and send a copy of the care plan to them within 24 hours of their discharge, using the method of sharing that allows the plan to be received as early as possible. It is important that plans are developed at the earliest opportunity after admission, and shared following discharge, including for people whose admission lasts less than 7 days.

Commissioners (clinical commissioning groups and local authorities) ensure that care plans can be shared within and across health and social care services within 24 hours of people being discharged from an inpatient mental health setting.

People leaving hospital after inpatient treatment for a mental health problem have a care plan for staying as well as possible in future, that they have helped to put together. The plan includes their recovery goals, how to cope with symptoms, what to do in a crisis, their medicines and treatment, and any work, training, learning or social activities. Their mental health practitioner should make sure a copy of this plan is sent within 24 hours of their discharge to everyone who will be involved in supporting them.

Source guidance

Transition between inpatient mental health settings and community or care home settings (2016) NICE guideline NG53, recommendation 1.6.3

Definitions of terms used in this quality statement

Care plan

A care plan for discharge from an inpatient mental health setting is based on the principles of recovery and describes the support arrangements for the person after they are discharged. It should include:

  • discharge address

  • possible relapse signs

  • recovery goals

  • who to contact

  • where to go in a crisis

  • budgeting and benefits

  • handling personal budgets (if applicable)

  • social networks

  • educational, work-related and social activities

  • details of medication

  • details of treatment and support plan

  • physical health needs including health promotion and information about contraception

  • date of review of the care plan

  • follow-up requirements following discharge, including method of communication for follow-up.

It is important that the process of care planning is person-centred and that people are involved in developing their own care plan (see quality statement 8 in the quality standard for service user experience in adult mental health services).

[NICE's guideline on transition between inpatient mental health settings and community or care home settings, recommendation 1.5.20 and expert opinion]

Everyone involved in a person's care

People involved in providing support to the person at discharge from an inpatient mental health setting and afterwards should be listed in the care plan. This is likely to include the person's GP, community mental health teams (including crisis teams), social workers and other local authority services, and carers.

[Adapted from NICE's guideline on transition between inpatient mental health settings and community or care home settings, recommendation 1.5.20 and expert opinion]

Equality and diversity considerations

In some cases, it might not be appropriate to fully involve people in developing their own care plan, or to share the plan with them, for example when a person lacks capacity. Independent advocates can represent people's interests and support them to obtain the services they need.