Transition from aftercare

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Each person will progress through aftercare at a different pace. Transition from the service must be well-organised, gradual and supported in consultation with the individual and their support network.

Key principles for effective transition from aftercare

  • Formal transition processes
  • Early preparation
  • Empowering and encouraging consumers
  • Good communication and shared responsibility
  • Individualised transition plans
  • Follow up

These principles are detailed in the Key Principles for Transition Care, which guides clinicians and healthcare services to improve healthcare for young people transitioning to adult services. They also apply in the context of aftercare.

Gradual transition

As the consumer’s wellbeing improves, reduce the frequency of engagement to support their gradual transition out of the aftercare service. Discuss this with the person to ensure it aligns with their needs.

Cover the following in the final two meetings with the consumer:

  • Review of safety and support plans.
  • Confirmation of ongoing care plan.
  • Communication with the care team and referring provider regarding transition out of the aftercare service (with consent).
  • The involvement of family, carers, friends or kin (with consent).
  • Consideration for gradual transition, caring contact or re-entry, if required.
  • Celebrating successes and achievements – planning for a “good” goodbye.
  • Storytelling and capturing their experience in a person-centred manner.

Unplanned transition

Consumers may unexpectedly discontinue the program for various reasons. Establish clear guidelines on how to manage this, in collaboration with local governance groups, considering:

  • what length of time with no contact is considered an instance of unplanned discontinuation
  • how long to continue attempts to make contact
  • ongoing caring contacts
  • the process for closing the person's file
  • communication required with other care providers or family members, carers, friends and kin (if consumer consent was provided)
  • the process for re-entry to the program if the consumer wishes to resume services
  • data collection that may inform engagement and retention rates.

Advise consumers about this process during onboarding.

Caring contacts

People may benefit from brief caring contacts (e.g. texts, calls, postcards or letters) at the end of their aftercare program. This may be for a period up to 12 months, as determined by the needs of the person and service capacity.

Evidence shows that caring contacts can reduce re-presentation to hospital for self-harm1 and re-occurrence of suicide attempts2, between 12 and 18 months following an initial suicide attempt.

Re-entry

Previous access to aftercare services does not preclude people from re-entering the program. This process will follow referral pathways as per entry to aftercare. Manage this according to service capacity; and track these trends to inform service delivery.

Frequent program access may indicate the need for an alternative approach. Talk to the person about whether the service is meeting their needs.

References

  1. Stevens GJ, Sperandei S, Carter GL, et al. Efficacy of a Short Message Service Brief Contact Intervention (SMS-SOS) In Reducing Repetition of Hospital-Treated Self-Harm: Randomised Controlled Trial. Br J Psychiatry. 2024 Mar;224(3):106-113. DOI: 10.1192/bjp.2023.152
  2. Suicide Aftercare Services: An Evidence Check Rapid Review Brokered by The Sax Institute for The Commonwealth Department of Health and Aged Care. Sydney (AU): Sax Institute; 2023 [cited 25 Sept 2024].
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