Transition to Recovery

Published 9 December 2019. Last updated 12 December 2019.

Transition to Recovery (TRec)


Feedback from the Mental Health Service consumer experience and staff surveys indicate that patients are leaving inpatient services with limited understanding of their goals for post-discharge care, and community mental health staff are not always aware of the transfer of care goals for clients referred from the inpatient service. Often these issues lead to avoidable readmissions or delayed discharge due to not having adequate support within the community. This project addresses these challenges through collaborative care planning.

View a poster from the Centre for Healthcare Redesign graduation, December 2019.

Transition to Recovery [poster]


To increase collaborative care planning from acute hospital units to community mental health services and to improve the service experience of consumers, carer and families.


  • Increased percentage of newly referred people from the acute inpatient mental health unit who meet with the clinical care coordinator from the community mental health team for discharge planning prior to discharge.
  • Increased percentage of acute post-discharge community care follow up within seven days, from 29% to 75%, by December 2020.
  • Improved staff experience of transfer of care process, from admission to the acute inpatient mental health unit to the community mental health service team.


Care planning plays a fundamental role in preparing consumers, carers and families to transition from hospital to the community and ‘is widely recognised as a key process in achieving continuity of care for persons leaving the hospital.1-2 For consumers living with mental health illness, effective care planning in genuine partnership with consumers, carers and families, has been demonstrated to influence both hospital admission rates and quality of life.

The National Safety and Quality Health Service Standards (NSQHS) sets out clear criteria for ‘Partnering with Consumers’ (Standard 2) as part of requirements for service accreditation.3 The strategic goals and initiatives for HNELHD Mental Health Service Strategic Plan 2019-2021 also include enhancing consumer engagement and quality care planning.4

Further, completion of care plans has been trending down with only 24% of care plans completed (with 20% of those completed being done so with consumer involvement) in April 2019. The mental health service is experiencing an increasing number of people who are readmitted within 28 days of discharge from the mental health inpatient units, at a cost of approximately $2.5M to the service in 2018.


  • Process mapping sessions informed a thorough understanding of the challenges inhibiting the successful completion of care plans by clinicians with consumers.
  • Diagnostics also included literature guided analytics, patient, carer, family and staff interviews, YES (Your Evaluation of Service) survey data, data analysis, literature guided analytics, and implementation capability audits.5
  • Brainstorming groups, other workgroups and the Transition to Recovery (TRec) Steering Committee were convened to create and prioritise solutions, including:
    • creating an integrative Individual Recovery Plan which includes all aspects of the person’s treatment plans, the person’s own recovery goals, needs of the family and carers. The Individual Recovery Plan is a live document that is to be used as reference point during the transition of care as well
    • redesigning clinical review meetings to include patients, carers, families, and care coordinators in a meaningful and inclusive way.


Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.


January 2020 – December 2020

Implementation sites

Newcastle Mental Health, Hunter New England Mental Health, Hunter New England LHD


  • Centre for Healthcare Redesign – presenters and support staff
  • Professor John Wiggers – Director, Health Research and Translation and Population Health
  • Consumer Participation Unit – Hunter New England Mental Health
  • Flourish Australia – Newcastle
  • Private medical professionals on steering committee


Implementation success will be measured against:

  • various performance indicators, including YES and Mental Health Carer Experience Survey results5-6
  • completed Individual recovery plans with patient
  • carer, family and care-coordinator involvement
  • re-admission rates as well as the average length of stay in an inpatient unit
  • 48-hours follow up phone calls and acute post discharge community care
  • seven day follow up on key performance indicators.

Care coordination for seamless transfer of care

  • An integrated care coordination pathway with clearly defined roles, triggers and referral criteria for early referral for community care coordination to facilitate the early community mental health in-reach into the acute units.
  • Development of a role, within current resources to act as ‘community liaison’ who works across the inpatient and community teams with skills and accountabilities to include:
    • experience in effective care brokerage
    • enabling appropriate referrals
    • broad understanding of community resources/pathways available and capacity to keep up to-date (through close connection with community partnerships manager).

Collaborative care and discharge planning

  • One Collaborative Care Plan – This will be rebranded as an ‘Individual Recovery Plan’ for consistency with community managed organisations and in line with Living Well: A Strategic Plan for Mental Health in NSW 2014-2024.7 It will be designed to:
    • be completed with the consumer to support the development of short, medium and long-term treatment and recovery goals started in the inpatient unit and continued into the community (using a biopsychosocial model)
    • incorporate requirements for safe transfer of care between the inpatient and community teams. In keeping with the Lean method, the use of the Individual Recovery Plan would make other transfer of care documents in current use unnecessary.
  • A peer worker was assigned to work across both community and inpatient services to help enable the involvement of the consumer in the development of the Individual Recovery Plan and uptake by both inpatient and community teams.

Collaborative clinical review meetings

  • Recovery-oriented language is not yet incorporated in inpatient process to enable understanding of inpatient staff role. We therefore seek to rebrand the 'clinical review meeting' to the 'recovery planning meeting’.
  • A care coordinator will attend the recovery planning meeting  to participate in the development of the ‘Individual Recovery Plan’ with the multidisciplinary team and consumer, family and carer input.
  • Recovery planning meetings are to be conducted frequently and during a timeframe which allow all stakeholders and consumers to attend the meetings in a safe space, and conducted in an inclusive manner through the use of plain language as well as including the voiced needs of consumers and their carers and families.

Lessons learnt

  1. Significant confusion existed around the terms ‘Care Plan’, ‘Transition of Care Plan’, ‘Treatment Plan’ and ‘Discharge Plan’. The documents and terms are used interchangeably, and often in isolation. In this case, vital treatment information or person recovery needs can be omitted in the provision of care, as clinicians and carers do not consult the various documents.
  2. Diagnostics identified  numerous issues  and helped inform and prioritise the decisions around which areas to address.
  3. Key performance indicator data does not often reflect an accurate picture of what is happening on the ground. This required advice and ongoing action from Hunter New England Mental Health Service data manager through the TRec Steering Committee to help us understand how we can better measure quality transfer of care from inpatients to community services.
  4. Both inpatient and community staff want to change and create a better service for consumers, and felt empowered by the co-designing process followed, as they had the opportunity to share their experiences and concerns, but also create solutions.
  5. Obtaining the input of consumers and carers has proven more challenging due to the disenfranchised patient groups. The time required to engage with a valid consumer and carer sample, for a comprehensive, cross section of perspectives conflicted with project timeframes, so this has been built into plan-do-study-act cycles during implementation.
  6. Engagement with families and carers has been both confronting and encouraging, as we have learnt from their challenges and witnessed their despair as they try to navigate a system that is often inconsistent, all the while maintaining a sense of hope and optimism for their loved one and their future.


  1. Nurjannah I, Mills J, Usher K, Park T. Discharge planning in mental health care: an integrative review of the literature. Journal of Clinical Nursing. 2013;23:1175-1185.
  2. Haggerty JL, Reid RJ, Freeman GK, et al. Continuity of care: A multidisciplinary review. British Medical Journal. 2003;327:1219-1221.
  3. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards: Partnering with Consumers Standard. 2nd ed. Canberra: ACSQHC; 2018.
  4. Hunter New England Local Health District. Mental Health Service Strategic Plan 2019-2021. Newcastle: HNELHD; 2019.
  5. Australian Mental Health Outcomes and Classification Network. Your Experience of Service Surveys. Sydney: AMHOCN: 2015.
  6. Australian Mental Health Outcomes and Classification Network. Mental Health Carer Experience Survey. Sydney: AMHOCN: 2017.
  7. Mental Health Commission of New South Wales. Living Well: A Strategic Plan for Mental Health in NSW 2014-2024. Sydney: MHCNSW; 2014.

Further reading

  • Steffen S, Kosters M, Becker T, Puschner B. Discharge planning in mental health care: A systematic review of the recent literature. Acta Psychiatrica Scandinavica. 2009;120:1-9.
  • Xiao S, Tourangeau A, Widger K, Berta W. Discharge planning in mental healthcare settings: A review and concept analysis. International Journal of Mental Health Nursing. 2019;28:816-832.


Elizabeth Roberts
Clinical Nurse Consultant
Newcastle Mental Health
Hunter New England Local Health District

Belinda Border
Service Design Lead
Hunter New England Mental Health
Hunter New England Local Health District

Christine Love
Professional Lead – Peer Work
Hunter New England Mental Health
Hunter New England Local Health District


Fill in our feedback form to find out more about this project or get in touch with the project manager.

Is this your project?

Fill in our feedback form to update your story or contact details.

Browse similar projects

Mental healthHunter New EnglandPrimary careMetropolitanCentre for Healthcare Redesign
Back to top