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Supporting Effective Transitions of Care

Written by Laura Steadman






The period immediately following discharge from inpatient mental health facilities has been found to be the time of greatest risk for adverse outcomes including relapse, self-injury and rehospitalisation.

In Queensland, the Acute Care Team provide follow-up and crisis response to strengthen effective transitions out of hospital for patients of the mental health service. For general health however (i.e., medical and surgical patients), the need for community intervention for psychological symptoms is more commonly overlooked.

In Hospital In the public system, inpatient psychologists work to conduct psychological assessment and brief therapeutic intervention targeted at reducing distress and increasing comfort during each admission. Importantly, inpatient psychologists seek to determine if the client’s response is clinical in severity, or if it could be categorised as a normal response given the circumstances.

Referrals to inpatient psychologists vary, and include: emotional support related to adjustment, such as a new diagnosis or decline in function; distress management during admission; or to assess and intervene in pre- existing mental illness exacerbated by the inpatient environment. Meeting with a psychologist whilst in hospital can also be effective for stigma reduction, reducing existing barriers to accessing help. However, this intervention is limited to the duration of one’s hospital admission and capacity of inpatient services.

On Discharge Often clients are discharged into GP care for continued management of their medical or surgical condition. Continued GP care provides a valuable opportunity to monitor clients’ mental states and determine if a referral to a psychologist in the community would be beneficial.

Some symptoms to monitor include changes in mood, increased irritability, greater difficulty completing tasks that the client used to find easy, and worries that impact daily function.

At True North Psychology, we would love to continue to collaborate with you to increase the effectiveness of transitions from hospital to outpatient and community settings. We are committed to improving health and wellbeing outcomes, and collaborating in care.


1. Mutschler, Lichtenstein, Kidd & Davidson (2019). Transition experiences following psychiatric hospitalisation: A systematic review of the literature. Community Mental Health Journal, 55, 1255-1274.

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