Key points about client discharge and transfer of care

• Clients, family (where appropriate) and other care providers are key partners in client discharge and transfer of care planning.
• Discharge and transfer of care planning is a part of assessment and treatment planning which is continually reviewed and updated throughout treatment.
• Organisations need defined processes to ensure all clients have appropriate discharge and transfer of care plans in place when exiting the service, whether scheduled or unscheduled.
• Discharge and transfer of care plans respond to individual client needs, circumstances and risks.
• Documented discharge and transfer of care plans are to be readily available to the client and those involved in providing treatment and care with the client.
• Discharge summaries are created at the end of all client treatment episodes and recorded in the client’s health record.
• Transfer of care includes following up with clients and other service providers to check if further assistance or information is required.
• Improving client discharge and transfer of care is a shared responsibility by all service systems stakeholders.

Practice tips for AOD service providers

• Discharge and transfer of care policies and procedures address roles and responsibilities, delegations, discharge criteria, required care planning actions (including managing unscheduled client exits), referral, documentation requirements, information administration, and client feedback requirements.
• Use structured discharge planning and transfer of care forms and checklists to guide consistent, documented and complete practice.
• Ensure release of information consent form are signed when there is an intent to transfer care to another service provider.
• Provide staff with orientation and training on discharge and transfer of care processes.
• Facilitate engagement with continuing care service providers before the client is discharged from the service.
• Ensure clients have necessary information and supports for them to enact the discharge and transfer of care plan, and how to connect with additional support if needed, including a return to the current service where appropriate.
• Prepare for instances where a client may leave the service before the scheduled time by initiating discharge and transfer of care planning as part of treatment planning and review. Have a ‘split kits’ inclusive of health advice, emergency information and additional referral information which can be given to all clients who are discharging early.
• Implement the gathering of feedback, including patient reported experience measures (PREMs), through routine discharge and transfer of care practice.
• Conduct regular audits of client health records to assess client discharge and transfer of care practice, and identify where improvements can be made.

Referral and transfer of care communication can be improved between clinicians and agencies by applying ‘ISBAR’ guidelines

I - Introduction: Introduce who you are, your role, where you are from and why you are communicating,

S - Situation: Explain the clients current situation.

B - Background: Provide information on issues that led to the client's current situation.

A - Assessment: Explain what you think the problem or need is for the client.

R - Recommendation: Provide a recommendation or request for the client.

Further information

• NSW Health Clinical Handover – Standard Key Principles
• NSW Health Drug and Alcohol Psychosocial Interventions Professional Practice Guidelines
• NSW Health Drug and Alcohol Withdrawal Clinical Practice Guidelines
• Non-government Organisation Alcohol and Other Drugs Treatment Service Specifications

Feedback

Email: moh-aodsafetyquality@moh.health.nsw.gov.au​