Discharge Planning

Consider ways to support aftercare for someone hospitalized for a mental health emergency,
including what to do if they might be suicidal.

How can I plan for my loved one’s discharge from a hospital? 

Discharge from a mental health facility can be stressful for the individual and their care partners—the people who support them. Unfortunately, too many people with severe mental illness (SMI) are discharged before psychosis is resolved or plans are well formed for follow-up care or housing. Many state laws allow for a commitment period of “up to” a certain time frame, giving providers authority to discharge any time. Reasons may be related to commitment criteria, insurance reimbursement, resource shortages, or a belief that treatment is ineffective.

Because of those realities, advocacy for appropriate discharge can be critical and begins as soon as the person is admitted.

Consider advocating for AOT upon admission

Assisted outpatient treatment (AOT) is court-ordered care in the community. In most places that utilize AOT, a referral is made while the person is an inpatient, so they are court-ordered to follow a treatment plan when they discharge. If an AOT petition is filed and the person meets criteria for AOT, a program needs to be available to serve them. Sometimes there are waiting lists, so filing a petition when hospitalization begins might increase the chances that AOT could be part of the discharge plan.  

Pro tip: By researching whether AOT is available and connecting program staff to hospital staff, care partners might enable a warm handoff that would not have been arranged without their advocacy efforts.

Share mental health history right away

Do not assume that providers have immediate access to a person’s past medical record or that crisis responders will share documents they collect. Sharing a mental health history each time a person enters a facility or is transferred to a new facility or program improves chances that evaluation and treatment are based on medical history and not just how a person might present in the moment.

TAC provides a fillable form, within an explanatory article, that helps care partners build a concise history that can include a timeline of episodes and events, signs and symptoms, past experiences with medications, and more.

Fax or hand deliver the mental health history with a brief cover letter explaining your relationship to the patient, your level of involvement with current and past care planning, and what your support role might look like at discharge. If you have guardianship or if there is a psychiatric advance directive, be sure to include that information. 

HIPAA protects important relationships by allowing providers to accept information shared by care partners without disclosing that information or its source to their patients. Federal confidentiality laws do not require a signed release of information for providers to accept, consider, and file medical information shared by family or friends. Please refer to TAC’s article about HIPAA for more information.

What if I disagree with the decision to discharge?  

Care partners often find that their opinion about whether someone is stabilized and ready for discharge may differ significantly from those making decisions. While it may not be possible to change a discharge decision, engagement is the best chance to see that discharge plans are based on the most complete information possible and not dependent on assumptions that may be incorrect. 

For the best chance at a collaborative response, care partners need to keep emotions in check and remain professional. Here are some questions to consider asking: 

• What do I need to know to support my loved one? 
• What should I plan for, to keep everyone safe?  
• If there is a mental health emergency right away after discharge, who can I contact? 
• If something goes wrong post-discharge, is there someone at the hospital I can contact who manages reports related to serious adverse medical events?  

What if my loved one is suicidal?  

Numerous studies have consistently reported that individuals are at high risk of suicide after discharge from psychiatric inpatient care. If you believe your loved one is at risk for suicide, provide a clear explanation for your concern and document any past attempts, threats, or acts of self-harm. Ask to speak with a clinician about your concerns and ask if the clinician believes your loved one is at risk for suicide. You can explain that you want help to know how to keep them safe after discharge.  

The Journal of the American Academy of Psychiatry and the Law offers Probable Standards of Care for Suicide Risk Assessment. The article mentions that “findings of negligence frequently occur when suicide risk was not reassessed at critical treatment transitions such as psychiatric discharge.” 

The article explains that a clinician is responsible to review pertinent documentation, including by gathering “collateral reports from other professionals, family, or significant others.” The article states that “negligence is often found when records have not been obtained or reviewed, partly because failing to do so allowed critical information to go undetected.” 

Citing a review of court practices, the article points out that over-reliance on a patient’s own statement that they won’t harm or kill themselves could be viewed as substandard care: “Comments after the fact that one didn’t call relatives or prior caregivers for information because of ‘confidentiality’ ring hollow to a jury when it is obvious that the patient was in danger.” 

What can I ask for? 

If your loved one is being discharged and has signed a release of information (ROI) so facility staff can speak with you, request a meeting to go over the care plan while your loved one is still in the facility. Arrive with questions written down and well organized to honor everyone’s time. Be sure to ask for any information you need before your loved one leaves. After they leave, staff may be unwilling to honor the ROI or respond to you at all. 

If your loved one hasn’t signed a release of information (ROI), you might need a workaround to gather the information you need if you will participate as a caregiver after your loved one goes home. For example: 

• Explain that you are not asking for confidential records or information that would violate confidentiality laws. Become familiar with HIPAA so you feel prepared to explain how your request isn’t asking the provider to violate HIPAA.  
• Ask for general information on how a caregiver can best support a loved one with SMI or a more specific diagnosis.  
• Ask for guidance about how to manage a household with someone experiencing symptoms of psychosis.  
• Request resource information about what to do in a crisis or whom to call if certain issues arise.  

What if I have guardianship? 

If you are a legal guardian, your right to participate in care planning and discharge planning is broader. Providers are responsible to share information with any individual who has a specific legal contract making them a “personal representative,” such as someone with guardianship, conservatorship, or power of attorney.  

According to the U.S. Department of Health and Human Services (hhs.gov), the HIPAA Privacy Rule states that a “personal representative must be treated as the individual.”  This federal guidance document explains that a personal representative “stands in the shoes of the individual and has the ability to act for the individual and exercise the individual’s rights.” TAC provides an article with more information about guardianship.  

What if I don’t feel safe bringing them home with me? 

If family are willing to take their loved one home, that is often the preferred discharge plan. In fact, our society has become very dependent on family members and loved ones acting as de facto caregivers. Sometimes it is not a safe option, though, due to aggressive behaviors associated with psychosis, drug use, the needs of others in the home, and more. 

Caregivers need to be clear about their boundaries and reject pressure to ignore safety concerns, despite how painful these decisions can feel. It is not a rejection of a loved one; it is a recognition that those with SMI and those supporting people with SMI are entitled to their own safety and wellbeing and sometimes that cannot happen in the same residence.  

TAC provides an article with information about safety planning, including suicide risks and what to consider if someone becomes violent due to an untreated or under-treated SMI condition. 

For more guidance about caring for yourself when someone you love is forever changed by SMI, refer to TAC’s materials about coping with ambiguous loss.