Transferring or discharging patients
Psychiatrists have an obligation to arrange continuity of care for all current patients and to make provision for other active patients, including those who return on a regular but infrequent basis.
Stages of transfer/discharge
The process of transferring and discharging patients involves advance planning and can essentially be divided into three stages:
1. Preliminary preparation:
- reviewing patient files
- identifying psychiatrists/other health care professionals whom transferring patient care to may be suitable
- planning handover with patients
- preparing handover documents
- informing patients of pending closure
- informing patients’ general practitioners (GP) of pending closure
These issues are discussed in greater details as follows.
1. Preliminary preparation for informing patients
To help facilitate discussions with patients about the decision to close up, it is highly recommended that, before doing so, the psychiatrist has reviewed the patient’s file, identified alternative therapist options and prepared a tentative handover plan to general practitioners and other relevant medical practitioners. Re-adjustment of the psychiatrist’s action plan for each patient may be required during the file reviews as older documentation on the patient is considered.
As GPs are a key link in the primary health care system, consideration should be given to their role as coordinator in patients’ ongoing care. Consideration should also be given to transferring patient care to disciplines other than psychiatrists, where appropriate. For example, social worker, psychologist, or referral back to general practitioner.
Identifying potential receiving psychiatrists or other health care professionals can be done through one’s own professional network. An alternative source is the RANZCP ‘Find a ‘Psychiatrist’ database. The patient’s ability to travel to the location of alternative health care providers should be taken into consideration. All potential receiving psychiatrists should be contacted to better understand their profile and availability. Although this is labour intensive, it is a sound platform for a good handover.
As medical practitioners have a legal and ethical duty to provide continuity of care for their patients, transfer of care/discharge discussions and decisions are an important aspect of patient care when closing a practice. Predicting the pace of handover decisions is difficult and will vary greatly between patients. There is a need to be alert to signals of change of mind by patients and, therefore, handover decisions should remain open for review throughout the process.
During this phase of transfer/discharge, psychiatrists will need to prepare a comprehensive handover, including a summation of patients’ history, for the patient’s GP and/or receiving psychiatrist/other health care professional. The preparation of these documents may require considerable time and, accordingly, psychiatrists should allow adequate time. Consideration should be given to providing patients with a copy of the summary handover documents provided to the receiving psychiatrist or health care professional.
Communicating outstanding test results is an important aspect of the closing up process. Psychiatrists should have processes in place to ensure that test results are followed up on and that a copy is provided to the patient and to their receiving health care professional and GP.
Letters to both patients and health care professionals will also need to be prepared to advise them of the intention to close up. All letters will need to include:
- the limits of availability
- how health records can be accessed
- future contact details.
A sample letter for notifying patients of the intention to close up is available on the RANZCP webpage.
Attaching an individualised checklist to each patient’s file is useful as it serves as a reminder and record for each step in the transfer of care/discharge process.
3. Informing patients
Before informing active patients of the decision to close a practice, psychiatrists should take into consideration their relationship with the patient, the patient’s profile, and the complexity of handover decisions that will need to be made. These factors will influence the estimated length of time for discussions and decisions during the handover phase and, therefore, how soon to tell patients of the decision to close up. Psychiatrists should be aware that, when the decision is to inform the patients in person, notification processes may be taxing and difficult. In these circumstances, staggering the notifications is a good idea.
Consideration should also be given to the reason(s) that will be disclosed to patients as to why the practice is being closed and the methods that will be used to inform them. A range of options exist for this. For example:
- placing a notice in the practice waiting room and/or on the entrance door
- requesting a receptionist advise via telephone
- informing a patient in person during an appointment
- publishing a notice on the practice webpage
- informing via a letter or an email.
Simultaneous notification in writing of the patient’s GP or specialist, advising that a full handover will follow, is recommended.
Psychiatrists should be aware that telling patients of the decision to close up can affect the balance of the treatment relationship. Patient reactions may include anxiety, grief, protest, wanting more, flight into health and expressions of empathy. Some patients may want reassurance about their psychiatrist’s health and all will want to discuss the situation and their future options.
For some patients the depth of psychosocial work and appointment frequency may increase. Others may perceive their psychiatrist’s notification to close up as rejection and may be vulnerable to acting out their despair. The psychiatrist should be alert for signs of depression, regression, flight into health, delays in ‘letting go’ of the therapist and even suicidal ideation.
Record keeping of transfer/discharge process
To assist with this process it is recommended that a schedule is created in a spreadsheet, which will also serve as a long-term reference, to record:
- patient names
- patient profiles of, e.g. the needs of patient, frequency of appointments
- whether patients are active or inactive
- whether patients will be discharged or transferred
- ideas/options for transfer of care
- names of potential receiving psychiatrists or other health care professionals
- final choice of receiving health care provider.
Summary of key points for transfer of care/discharge planning
- Allow time for the preparation of handover information
- Maximise patient input into transfer/discharge plan.
- Ensure preparation of handover summaries, letters to patients, receiving health care professionals and referring GPs.
- Involve referring general practitioner in planning and ongoing involvement, where appropriate.
- Consider discharge to a patient’s GP.
- Clarify information, timelines, options, availabilities and recommendations with patients.
- Be flexible in the planning and provision of care up to the point of transfer/ discharge.
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This information is intended to provide general guide to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available.