Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
Inconsistent discharge processes impact flow and follow-up. This project examined consumer and carer perceptions and preferences for effective discharge planning.
Dates: 1 March 2024 - May 2026
Implementation sites: Princess Alexandra Hospital Community Mental Health centres
This project was presented as a poster at CEQ Showcase 2026 (PDF 145KB).
Aim
The project aimed to determine
- if structured approaches to Collaborative Relapse Prevention planning (CCRP) would increase consumer confidence to navigate the post-discharge periods and reduce barriers to timely re-access.
- which CCRP is preferred by consumers and their carers.
Outcomes
- Consumers rated the usefulness of the CRPP at an average of 8/10, while carers rated it at 8.5/10.
- Consumers most frequently selected 'Strengths (what keeps me well)' (24%) and 'Triggers and warning signs' (23%), followed by 'How to re access the service' (14%), 'How can others best help me' (12%), and ‘Family involvement and education' (9%).
- Carers prioritised 'Triggers and warning signs' (25%) and 'Family involvement and education' (18%), followed by 'Crisis planning' (14%) and 'How to re access the service' (14%).
Background
Discharge from mental health services is a vulnerable time which directly affects patient flow, continuity, and timely follow-up. While relapse prevention planning (RPP) can address these concerns. And internal audit showed that RPP was inconsistently documented, was largely verbal, and lacked meaningful collaboration with consumers, carers. It is possible that these gaps contributed to preventable relapse, avoidable re-presentations, and disruptions to service flow.
To address this, the CRPP model was introduced. The model was co-designed with lived experience staff. The CRPP training, session structures, and three flexible documentations were developed to support personalised planning. The resources aimed to strengthened communication, encouraged inclusion of social networks and external providers.
Methods
To evaluate the intervention a quantitative survey design measures at three transition points.
Discussion
The pilot study sought to address a gap in discharge planning. The intervention was delivered on an individual basis. While the sample of consumers and carers was relatively small, the project has been able to demonstrate that structured discharge planning can promote more collaborative and person-centred approaches to discharge planning.
References
Fossey, E., Harvey, C., Ennals, P., Wiggins, A. & Farhall, J. (2023) From evidence to realities: psychosocial intervention provision in Australian routine community mental health practice, Psychosis, 15:2, 155-167, DOI: 10.1080/17522439.2021.2023615
Gumley A.I., Bradstreet S., Ainsworth J., Allan S., Alvarez-Jimenez M., Birchwood M., Briggs A., Bucci S., Cotton S., Engel L., French P., Lederman R., Lewis S., Machin M., Maclennan G., McLeod H., McMeekin N., Mihalopoulos C., Morton E., ... Gleeson J. (2022). Digital smartphone intervention to recognise and manage early warning signs in schizophrenia to prevent relapse: the EMPOWER feasibility cluster RCT. Health Technology Assessment, 26(27), v-122. http://dx.doi.org/10.3310/HLZE0479
Kates, N., Sunderji, N., Ng, V., Patriquin, M., Alloo, J., Mirwaldt, P., Burrell, E., Gervais, M., & Siddiqui, S. (2023). Collaborative Mental Health Care in Canada: Challenges, Opportunities and New Directions. Canadian Journal of Psychiatry, 68(5), 372–398. https://doi.org/10.1177/07067437221102201
Key contact
Okgi Sargent
GP Shared Care Nurse Navigator
Metro South Hospital and Health Service