On exit from a service or transfer of care, people are actively supported by mental health practitioners through a timely, relevant and structured handover, in order to maximise optimal outcomes and promote wellness.
The mental health practitioner:
- Prepares people and families/carers for exit from the service or transfer of care
- Adheres to policies and procedures regarding transfer of care, with a focus on recovery and health promotion
- Regularly reviews the transfer of care plan with the person and family/carers in respect to clinical status, the person’s and family or carer’s wishes and estimated date of transfer
- Assesses the person, completes relevant outcome measures and obtains feedback from the person and family to support decision making related to planning for transfer of care
- Clearly identifies and follows through on roles and responsibilities in partnership or shared care arrangements, including engaging in assertive follow-up
- Provides the person and, with the person’s informed consent, their family/carer and relevant agencies with information to support transfer of care
- Provides clear documentation using designated forms and documents in a timely manner to the service where the person is being transitioned or referred, and consistent with privacy requirements