Hospital to Home – Expansion of psychosocial supports for people leaving hospital

Objective 11.6:

Improve the experience of people transitioning between hospital and the community

Action 11.6.2:

Connect patients with appropriate non-Government services while in hospital

The Hospital to Home (H2H) program commenced at the Prince Charles Hospital in 2016 in partnership with Richmond Fellowship Queensland. In 2019 Richmond Fellowship Queensland was contracted by Queensland Health to deliver the Individual Recovery Support Program in Metro North, which enabled the program to be expanded across all of Metro North Mental Health. The H2H program supports consumers/families through active engagement during an acute inpatient admission and the provision of ongoing higher intensity non-clinical support for up to three months after discharge.  This is then followed by lower intensity support period for up to an additional nine months.

An Independent Evaluation of H2H conducted in 2016/2017 found consumers engaged with H2H usually experience a reduction in the need for acute mental health admissions; are less-likely to be readmitted with 28 days of their last hospital admission; and are more likely to feel their have moved forward in their recovery, with a greater proportion of reported needs met. Over the first six months of operation in 2019, H2H supported 114 consumers.  One of the key areas seen as important to Metro North Mental Healt and Richmond Fellowship Queensland is promoting cross-sector service integration.  Accordingly, H2H staff can base themselves from any of the MNMH inpatient or community facilities to maximise consumer engagement as well as providing opportunities collaboration with the clinical team, to ensure integrated care is planned and delivered.

H2H is overseen by local committees at each of the facilities, who manage referrals and problem-solve operational issues.  H2H also maintains a broader MNMH steering committee to ensure consistency across each of the facilities and fidelity of the model.

Key achievements

  • Consumers and their families have access to an enhanced post-discharge support service not previously available across the Metro North Mental Health catchment
  • Development of cross-sector partnerships and multi service integration is woven into the model.

Key learnings

The importance of an integrated approach to mental health care involving key partners prior to discharge to ensure appropriate supports are in place.

What’s next?

H2H will continue to be implemented across the region, with ongoing monitoring via the local steering committees.

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.