Connecting people with care before leaving hospital

Objective 11.6:

Improve the experience of people transitioning between hospital and the community

Actions 11.6.2 & 11.6.3:

Connect patients with appropriate non-Government services while in hospital;

Promote shared responsibility for supporting clients to gain skills for community living while inpatients are preparing for discharge

Hospital-based in-reach supports by NGOs, in the form of Kiosks and Discharge Information Groups, are in place at each of the Metro North Mental Health inpatient facilities (TPCH, RBWH and Red/Cab).

The purpose of the in-reach support is to facilitate admitted consumers’ access to ongoing community-based supports prior to their discharge.  Having services come to the hospital cuts down on the need for consumers/families to navigate the broader community mental health sector without support.

Key achievements

Initially established and coordinated by North Brisbane Partners in Recovery (PiR) staff from 2016 to 2018, this project facilitated the successful capacity-building of hospital staff to coordinate this work into the future.

The project has had a significant impact in developing ongoing collaborative responses between the HHS and community organisations. The hospital staff now have a very good understanding of what services are in the community and how to engage them to facilitate positive transition outcomes for mental health consumers.

The in-reach support creates a regular NGO presence on mental health inpatient wards which allow opportunities for consumers and their families to access information, referral pathways, and social activities to support their preparation for transition back into the community.

The in-reach support has promoted ongoing collaborative responses between the HHS and community organisations. The hospital staff continue to maintain an active awareness of available community-based services and how to access them to facilitate positive transition outcomes for consumers.

Key learnings

Relationships between Hospital and NGO staff are key to successful delivery of collaborative initiatives.  The interest from NGOs seeking access to the kiosks has been very pleasing.

Each of the inpatient facilities across Metro North Mental Health are geographically separate and service different communities with different needs.  Accordingly, while the aim of the kiosks is to promote cross-sector integration, each inpatient facility may not consistently host the same NGOs across the region.

What’s next?

The in-reach support will continue to offer this valuable service and create opportunities for consumers/families to access information and services to support their smooth transition back to the community.

Get involved

If you would like to know more about Planning for Wellbeing, or if you’re interested in getting involved, please drop us a line – we’d love to hear from you.