Implementation guidelines for non-government community services

10.6 Exit and re-entry

Page last updated: 2010

The MHS assists consumers to exit the service and ensures re-entry according to the consumer's needs.

The intent of this criterion is to ensure that service providers assist consumers when they exit the service and provide them with sufficient information on how to re-enter the service if/ and/ or when required.

Access and information on services (criteria 10.6.1)
Development of exit plans (criteria 10.6.3, 10.6.4)
Re-entering the service (criteria 10.6.5, 10.6.6, 10.6.7)
Follow-up of consumers (criterion 10.6.8)

Access and information on services (criteria 10.6.1)

As appropriate to their circumstances, the consumer is given information about, referral or supported introduction to, community agencies which can offer support after they have exited the service.

Evidence that this criterion is met could include:
  • brochures about community services
  • documenting on individual consumer files that they were provided with information as part of the exit process, and that referrals and supported introductions were made where required.

Development of exit plans (criteria 10.6.3, 10.6.4)

Exit plans should contain the following: measurement of change in health status, satisfaction with service, perception of quality of life, review of goals, peer review, case discussion and methods used to evaluate outcomes, including the consumer's preferred evaluation methods.

Exit plans for child, adolescent and aged consumers need to be developed with consideration for issues specific to their demographic.

For example aged care consumers transferring to a nursing home and exit plans for child and adolescent consumers are not usually discussed at entry to the service provider.

Consumers, their families and carers should be helped to identify early warning signs of a relapse. Exit plans should include information about symptoms of pending relapse, sometimes called 'relapse signatures' and an accompanying relapse management plan, which includes information about accessible crisis services.

Depending on the type of service the consumer has received, the intensity and duration of service and whether the service provider was the primary case manager or a supporting service provider, the exit plan could include the following:
  • information for the preferred health care provider, for example the GP or private psychiatrist
  • the earliest possible involvement of the consumer's nominated service provider and arrangements for ongoing follow-up
  • community resources likely to be involved in post exit support and, as necessary, referral and facilitated introduction arrangements
  • other people to be involved and their roles
  • other details identified by the consumer and carers
  • preferred method of evaluating recovery outcomes for the consumer
  • details of follow-up arrangements with the consumer
  • plans for identifying early warning signs of relapse
  • information on how to re-enter the service
  • a clear point of contact in the service provider regarding the most recent episode of support
  • shared care arrangements with GPs, private psychiatrists and non-government organisations if applicable.
Evidence that these criteria are met could include:
  • exit plans
  • documenting exit interviews
  • providing information brochures to carers detailing available sources of ongoing support for them when a consumer exits the service
  • displaying posters and brochures in the organisation’s public areas
  • providing information on respite services, carer respite centres, carer resource centres and carer counselling programs
  • providing information on the service provider’s website when there is one. Top of page

Re-entering the service (criteria 10.6.5, 10.6.6, 10.6.7)

Arrangements for re-entry will depend on the type of service that has been provided. On exiting the service the consumer and their carers should be advised of the processes to follow should re-entry be required.

Evidence that these criteria are met could include:
  • exit interview documentation that re-entry information was provided to the consumer and their carers.

Follow-up of consumers (criterion 10.6.8)

This criterion is not applicable to the non-government community mental health sector.

For the purposes of this criterion, discharge is defined as discharge from an inpatient unit or discharge from an episode of care. The criterion does not apply to final discharge of the consumer from the mental health service.

Due to the relatively high risk of suicide in the first four weeks after discharge and to prevent relapse, the service provider, in conjunction with the treating clinician, is required to follow-up wherever possible within seven days of discharge. Consumers flagged for follow-up are identified by a risk assessment performed before they exit.

There is a clear and documented follow-up process which identifies the responsible agency and crisis service for the period following exit.

Policies and procedures to demonstrate compliance with Standard 10 Delivery of care will include those that address:
  • consumer rights and responsibilities
  • privacy and confidentiality
  • compliance with legislation
  • management of personal information
  • management of an informed consent process
  • management of situations in which the wishes and needs of a consumer conflict with the wishes and needs of their carer
  • clinical risk assessments for consumers
  • recovery-oriented mental health practice
  • service access - physical, social, cultural and information
  • service eligibility and priorities for access
  • referral and service entry arrangements
  • initial assessments
  • recovery planning
  • reviews recovery plans
  • exit planning
  • referral processes from the service to other services
  • consumer and carer participation in individual service planning and review
  • consumer and carer participation in organisational planning, program design and review and evaluation
  • consumer and carer representation on the organisation's committees
  • diversity responsiveness
  • use of interpreters, working with interpreters including Auslan interpreters
  • cultural assessments
  • carer rights and responsibilities
  • identification of carers
  • information provision to carers
  • how carers are involved at the individual, organisational and systemic levels
  • staff involvement in multidisciplinary interagency teams
  • engagement with mainstream community organisations such as sporting and recreational clubs, educational facilities, community employers and arts organisations as part of promoting recovery and community re-entry
  • engagement with local and regional carer support services, including specialist groups such as those for children of parents with a mental illness or culturally specific carer support groups, and how those links are established and maintained
  • safe transportation of consumers
  • occupational health and safety
  • safe home visits
  • medication and adverse medication event management (as appropriate to the type of service being provided)
  • managing verbal and physical violence
  • critical incident reporting and management
  • critical incident debriefing to assist staff, consumers, carers and other visitors when they have been exposed to a traumatic incident within the service
  • service and program review and evaluation
  • service quality and continuous quality improvement.
It is important to remember that policies and procedures alone are not sufficient to demonstrate that a service provider is meeting a standard's requirements. It is also necessary to demonstrate how the policies and procedures have been implemented and guide organisational practices and behaviours.