Discharge planning and Mental Healthcare Act 2017

Mahesh Gowda, Gopi Gajera, Preeti Srinivasa, and Shahul Ameen1

Address for correspondence: Dr. Shahul Ameen, Department of Psychiatry, St. Thomas Hospital,
Changanassery, Kerala, India. E-mail: moc.oohay@neemaluhahs

Copyright : © 2019 Indian Journal of Psychiatry

This is an open access journal, and articles are distributed under the terms of the Creative Commons
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INTRODUCTION
After an in-patient stay and an improvement in their symptoms, patients with mental illness may
have concerns and dilemma about the postdischarge life. They may find their future unclear and
themselves vulnerable. Factors such as the lack of insight, lack of social support, poor quality of
the patient-doctor relationship, and mistaken conclusions that the medications were not needed,
and poor awareness about the illness often contribute to noncompliance to treatment after
discharge.[1,2,3] Such noncompliance leads to a worsening of the symptoms; increased risk of
assault, dangerous behavior, and attempted or completed suicide; more extended hospital stay;
high costs; and decrease in the quality of life and impaired functioning.[1,4] The juncture of
discharge should be considered a significant event and also an integral part of the treatment
process. Discharge planning is “a formal process that leads to the development of an ongoing,
individualized program of care and support which meets the objectively assessed needs of a
patient/consumer on leaving the hospital. It addresses the social, cultural, therapeutic, and
educational interventions necessary to safeguard and enhance that person's health and well-being
in the community.”[5]

WHAT DOES MHCA 2017 SAY?

Mental Healthcare Act (MHCA) 2017[6] speaks about discharge planning in the following
sections.

Section 98.1
“Whenever a person undergoing treatment for mental illness in a mental health establishment
(MHE) is to be discharged into the community or to a different MHE or where a new psychiatrist
is to take responsibility of the person's care and treatment, the psychiatrist who has been
responsible for the person's care and treatment shall consult with the person with mental illness,
the nominated representative, the family member or caregiver with whom the person with mental
illness shall reside on discharge from the hospital, the psychiatrist expected to be responsible for
the person's care and treatment in future, and such other persons as may be appropriate, as to
what treatment or services would be appropriate for the person.”

Section 98.2
“The psychiatrist responsible for the person's care shall in consultation with the person above
referred, ensure that a plan is developed as to how treatment or services shall be provided to the
person with mental illness.”

Section 98.3
“The discharge planning under this section shall apply to all discharges (under section 86, 87, 89,
90) from a MHE.”
Thus, MHCA specifies that the treating psychiatrist should decide, in consultation with all
relevant parties, what interventions will be needed for a person with mental illness after the
discharge and how those interventions would be implemented. Moreover, section 98.1 also
specifies that necessary steps have to be taken not only during discharge but also when the care
of the patient is being transferred to another psychiatrist or when the patient is being transferred
to another MHE. Remember that, during such transfers to other MHEs, there are other
formalities too to be taken care of as specified in Section 93.1, i.e., “A person with mental illness
admitted to a MHE under section 87 or section 89 or section 90 or section 103, as the case may
be, may subject to any general or special order of the Board be removed from such MHE and
admitted to another MHE within the State or with the consent of the Central Authority to any
MHE in any other State: provided that no person with mental illness admitted to an MHE under
an order made in pursuance of an application made under this Act shall be so removed unless
intimation and reasons for the transfer have been given to the person with mental illness and his
nominated representative.”

WHY THESE CLAUSES?

India enacted MHCA 2017 as a consequence of it being a signatory to the United Nations
Convention on the Rights of Persons with Disabilities (UNCRPD). The above clauses in MHCA
regarding discharge planning are in line with the right of the mentally ill to live independently
and in the community as stated in the UNCRPD.[7] For the first time, discharge planning has
been mandated by the law and treating team is made responsible and liable. Moreover, we should
remember that even if MHCA or UNCRPD were not there, sound clinical practice automatically
entails preparing a discharge plan for ongoing care and rehabilitation of the patient. Research has
shown that psychiatric patients who receive adequate discharge planning are more likely to
utilize the outpatient services, less likely to become socially isolated, and less likely to require
immediate rehospitalization.[8,9,10]
Against this background, we searched for available literature on the practical aspects of
designing and implementing an adequate discharge plan. This article summarizes the major
findings.

AIMS OF DISCHARGE PLANNING

Discharge planning should be done with multiple aims in mind, the major ones being:
 Assisting with re-entry to the community
 Providing the support needed to sustain the progress that was achieved during the in-
patient care
 Achieving continuity and coordination of care and treatment
 Providing and mobilizing a level of support that corresponds to what the patient would
need for community living
 Minimizing the chances of relapse or immediate return to the hospital
 Preventing homelessness, suicide and/or being criminalized
 Ensuring early intervention during crisis and relapse
 Optimal health and well-being of the patient.[5]

ASSESSMENT
For the discharge planning to be effective, an assessment of the specific needs of that particular
patient should be first performed. Some domains that need attention during the assessment
include:
 Capacity for self-care: assess the patient's capacity, insight, and perception toward the
psychiatric illness. This will help us understand their current levels of functioning and the
potential need for support and assistance. Frequent assessment of the symptoms during
the inpatient stay will help in knowing whether the illness is responding to the treatment
and in recognizing chances of self-harm or aggressiveness in the immediate
postdischarge period. Assess whether the patient has the resources and ability to access
the medications that are being prescribed and to travel for the follow-up appointments.
This is especially important as difficult to travel is a major reason for nonadherence.[11]
Furthermore, assess what all strengths the patient has that would help him/her in future in
handling the illness and the various aspects of its treatment
 Clinical needs: identify the potential predisposing factors that can lead to distress or
relapse. The patient should be informed about the importance of sleep hygiene, nutrition,
lifestyle modification, anticipated adverse effects of the medication, and duration of
treatment. Appraise the patient about the early warning signs and teach them appropriate
techniques to cope with those factors and instruct them to immediately come for follow-
up whenever such factors become too severe to handle on their own. Furthermore, assess
the family's understanding of the illness and its treatment and the family's needs related to
the illness. Identify the immediate caregiver who can manage the emergency
 Other needs: assess domains such as socioeconomic, cultural, and spiritual. Discuss
where the patient would stay after the discharge: the levels of support available and
needed, the wishes and decisions of the patient and the family, and the recommendations
if any the treating team has in this regard should be taken into account, and a consensus
arrived at through discussions between all the relevant parties.[5,12]
For each area of identified need, a statement should be made about the service to be provided or
the action to be taken.

INVOLVE THE FAMILY

It is essential to keep the patient's family in the loop, especially in closed ward settings where the
patient is admitted without any bystanders. The patient's progress during the hospital stay and
how ready they are for discharge should be periodically discussed with the family. One study
pointed out that satisfaction in discharge planning drops when there is no contact between the
staff and the family regarding discharge.[13] Discharge planning meeting(s), in which the patient
and carers also take part and reveal their views, is another useful step. The date of discharge can
be planned as per the convenience of both the patient and the caregivers. A study found that a
higher percentage of patients who took part in collaborative discharge planning meetings became
involved in aftercare services compared to those who did not attend such meetings.[14]
Expressed emotion from the caregiver should be handled carefully and they should be
encouraged to facilitate the support and care which can lead to positive outcome during the
community living.

ARRANGING OTHER SERVICES

Community services available near the person's area can be utilized for crisis management,
supervision, support, compliance check, etc. We should evaluate such services and examine
which ones will best match the particular needs of a specific patient. Help should be provided to
the patient and the family to establish initial contact with such services. We can also share help-
line numbers for police, law, hospital, emergency contact, suicide prevention, etc.
If necessary, community-based services such as half-way homes and group homes should be
recommended to the patient if they are available, as they can provide sufficient care and support
required during the period of transition to community living. Patients may also require a referral
for medical care for medical comorbidities. Support groups such as alcoholics anonymous,
narcotics anonymous, al-anon, schizophrenia group, and other self-help groups can assist the
patient to sustain the recovery, and details of such organizations may be provided to patients and
family. Patients should also be informed about relevant government policies and programs and
prevailing benefits. Medical certificate and other required documentation should be provided to
the patient for referral.

SOME ESSENTIAL STEPS

Discharge planning should begin immediately after admission and be updated throughout the
inpatient stay.[15] We should ensure that the discharge plan sufficiently addresses the practical
and social reasons that influenced the admission. For example if a schizophrenia patient has been
re-admitted due to relapse following medication noncompliance since he is living alone, or if a
female patient with severe depression has a husband who suffers from alcoholism, such issues
should be addressed during the discharge planning.

ADDRESSING THE RIGHTS OF A PERSON WITH MENTAL ILLNESS

We should attempt to educate the patient about the changes in the mental health act. The
discussion should include the planning of an advance directive and nominated representative.
They should also be informed about the rights of a person who has a mental illness: specifically,
the right to confidentiality, the right to access medical records, and the right to legal aid.
Clarification about the release of medical records and its restriction should also be considered,
when applicable. They should be aware of the Mental Health Review Board (MHRB), its
function, and its involvement at the levels of admission, discharge, authorization for the advance
directive, nominated representative, raising a query, etc.[16]

LEAVE OF ABSENCE
Section 91 of MHCA 2017 mentions that the person can be given “leave of absence” from the
MHE subject to such conditions if any, and for such duration as such medical officer or
psychiatrist may consider necessary. Leave can be utilized as a step ahead of discharge for
admission under section 87, 89, and 90. We can stress upon the issues related to noncompliance,
aggression, impulsivity, and other reasons which leads to the admission. It is an observation
period, where the family can note the improvement and the responsibilities performed by the
patient. In the absence of community treatment option in MHCA, this provision can be
considered to ensure that the goal of the treatment and admission are achieved in the community
as well.

DOCUMENTATION
In the era of MHCA, documentation of all clinical decisions and actions is extremely important,
and this applies to discharge planning too. At the time of discharge, the patient should be given a
copy of the completed discharge instructions that include recovery goals, possible relapse signs,
ways to deal with them, and the details of whom to contact in case of emergency. It should
contain the name of the patient and signature of the treating psychiatrist so that it will not look
like a “generic” plan but one customized for the particular patient. A copy of the discharge
instructions should be stored in the patient's file as well as sent to everyone involved in providing
support to the person after discharge, with documented authorization for release of information.
The medical records should also contain documentation about the patients’ cognitive intactness
and the capacity for mental illness related decision. It should also be documented that the patient
understands and agrees with the discharge plan, including the medications and the follow-up
details.[15] It would be a good practice to use the regional language wherever applicable.
As a part of the obligation under MHCA 2017, chapter 3, section 10, the treating team should
propose for planning advance directive, nominated representative, and document his/her
understanding about illness and need for medication. It should include the measure to be taken in
case of relapse and noncompliance to medications. The patient should be educated about the
various treatment options such as oral and injectable medication, electroconvulsive therapy,
repeated transcranial magnetic stimulation, deep brain stimulation, and psychotherapy and their
preferences should be enquired about. Furthermore, preauthorization for proxy consultation will
help the clinician to identify the caregiver for future reference. This would ease the follow-up
procedure and maintaining compliance for the patient as well as the caregiver. The grievances
faced by the patient and caregiver should be addressed and directed to the MHRB whenever
necessary.
Routine use of any of the available checklists would ensure that no points are missed, especially
in busy settings. The options include discharge knowledge assessment tool,[17] discharge
checklist,[18] patient activation assessment form,[19] hospital discharge checklist,[20] and
taking care of myself guide.[21]

SOME LIMITATIONS
MHCA 2017 mandates the discharge planning to be done before any discharge from an MHE.
For a few cases such as immediate voluntary discharge, disagreement of the treatment plan, an
absence of capacity to consent for psychiatric illness, discharge against medical advice or other
emergency condition, adequate planning may not be possible. Rather, these are the situations
which require maximum planning and support, leading to a more grievous condition.
Furthermore, insufficiency of community psychiatric services and care homes limit the
possibilities of providing community support following discharge.

CONCLUSION
Discharge planning is a mandatory procedure as per the MHCA 2017. We could use this
opportunity to verify and document the goal set at the time of admission and target achieved at
the time of discharge. It can be a patient-friendly and highly practical approach to guide them
and improve their quality of life and mental health in the community. It can also reduce the
burden of family and caregiver. Thus, proper discharge planning can improve the outcome and
prognosis of the person with mental illness.

Financial support and sponsorship

Nil.

Conflicts of interest
There are no conflicts of interest.

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