Part 4: Supporting people after they leave an inpatient unit

4.1
In this Part, we cover:

• expectations for following up with people after discharge; and
• barriers to getting support after being discharged.

Summary of our findings

4.2
All DHBs consistently failed to meet the target to follow up with people within seven days of discharging that person from an inpatient unit. The target is for at least 90% of people to receive a follow-up contact but, on average, DHBs manage to follow up with only two-thirds of people within seven days. This is sometimes because of high caseloads for community mental health teams.

4.3
Even when follow-up contact is made, there can be barriers that prevent people accessing the services they need, including services that are outside the control of the health sector. Poor availability of suitable accommodation, especially for people with complex needs, is the largest barrier people face, and this can prevent some mental health patients from being discharged.

4.4
Some services are not available in all locations. Where they are available, long waiting lists can prevent people from getting timely access to those services.

Follow-up rates are well below expectations

4.5
DHBs are not meeting their own expectations that discharge plans will be actioned and followed up. The target that 90% of people are followed up with an initial contact from the community mental health team within seven days of discharge has not been met by any DHBs for at least the last three years. Many DHBs fall well short of the target. Nationally, only around two-thirds of people are followed up within seven days, and we found evidence that some people are not followed up at all.

4.6
Expectations for follow-up vary from within two days after discharge to no specified time frame. In our survey, there was clear consensus that the first contact should occur within the first seven days after someone leaves the inpatient unit. However, a few respondents said lack of staff capacity can interfere with this. In one DHB, we were told there is a lack of staff capacity in community mental health teams because of high caseloads.

4.7
We found in our case file review at three DHBs that between two-thirds and four-fifths of people with a plan for their mental health needs had a follow-up contact within seven days of discharge. However, we could not see any evidence of follow-up for the other people discharged.

4.8
Some of the people who were not followed up may have voluntarily decided not to engage with mental health services. Others may have been followed up by a different DHB. Most DHBs, including the three we visited, have policies and guidance about what to do when people do not show up for appointments or cannot be contacted. However, responses to our survey indicate that there are very few mechanisms for tracking individuals once they have left acute mental health care. The exception to this is those receiving secondary mental health support who have been allocated a keyworker.

4.9
Many of our survey respondents and staff we spoke to who work in inpatient units did not know whether people who had left their unit were receiving support. Overall, respondents indicated that there are no particular systems in place to ensure that people received follow-up care.

Barriers make it hard for people to get support after being discharged

4.10
We identified several barriers that prevent people accessing the services they need, when they need them. Many of these services are provided by agencies outside the health sector. The most significant of these barriers is a lack of suitable accommodation. There is also limited accessibility for some services in some areas of the country.

4.11
Many of these barriers are not within DHBs' control, so improving mental health services is not a challenge for just the health sector. Other agencies also need to be involved in meeting the needs of people with mental health problems. The Ministry recognises this and told us that it is working with other agencies to consider how the Government can better respond to mental health needs.

Accommodation

4.12
The most frequently reported service barrier we identified was finding suitable accommodation for people leaving an inpatient unit. The cost of accommodation is particularly a problem in some regions, and there is a shortage of accommodation options for people with complex needs. Workarounds are sometimes put in place, such as discharging people to caravan parks.

4.13
In all three DHBs that we visited, staff told us that people are kept in inpatient units when no accommodation can be found for them in the community or their families refuse to take them.

4.14
Some people stay in an inpatient unit for long periods (for example, two years) because of problems with access to suitable accommodation, rehabilitation, and other services in the community.

4.15
Keeping people in the inpatient unit longer than they need to be there takes up beds so that others cannot be admitted, or are discharged early to make room. As a result, there is a risk that accommodation issues rather than clinical need are influencing some discharge decisions.

4.16
The lack of suitable accommodation can mean that vulnerable people are living in loosely regulated and unsupported environments, and sometimes living with several unwell or dependent people.

Accessibility

4.17
What services are available can be different depending on where people live. Some services, such as detoxification, are not available everywhere and people have to travel to access them. We were told that, even within a DHB's district, access to services in the community was better in some places than others.

4.18
One DHB we visited had a shared care arrangement with neighbouring DHBs, which helped in providing a continuum of care for people moving around the region.

4.19
Despite this, that DHB still had some difficulty in arranging drug and alcohol services for people. It also did not have any services available to treat people with both acute mental health problems and other severe health conditions, such as diabetes. Mental health clinicians do not have the expertise to treat all of a person's medical conditions.

Other barriers

4.20
Other significant barriers include waiting lists, funding, and eligibility. For two of the DHBs we visited, access to services was problematic in about a third of cases we reviewed, either because of waiting times or entry requirements. In the other DHB, we were told that staff did not have information about waiting times to help them make decisions about referrals.

4.21
We were provided with examples of how inpatient unit teams in some DHBs were seeking to work together more closely and share information with other teams providing mental health services, such as with non-governmental organisations and community mental health teams, to be more co-ordinated and provide better continuity of care.

4.22
Failing to connect people with the services they need within an appropriate time frame after they have been discharged can make life more difficult for people. This can mean they are re-admitted to hospital sooner than might otherwise have been the case, or increase the demand on other health services.