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REVIEW ARTICLE

Discharge planning and Mental Healthcare Act 2017

Mahesh Gowda, Gopi Gajera, Preeti Srinivasa, Shahul Ameen1
Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, 1Department of Psychiatry, St. Thomas Hospital,
Changanassery, Kerala, India

ABSTRACT

Mental Healthcare Act 2017 mandates that proper discharge planning should be done and documented before any discharge
is done from MHEs. Discharge planning should be based on a thorough assessment of the needs of the patient. Family
should be actively involved in the planning process. Necessary steps should be taken for referral to other services, especially
those in the community. Discharge planning helps us to balance the goals of the treatment at admission, to reality check at
the time of discharge. Adequacy of discharge planning can be ensured by using various published checklists.

Key words: Discharge planning, Mental Healthcare Act 2017, Mental Health Professional

INTRODUCTION a patient/consumer on leaving the hospital. It addresses the

After an in‑patient stay and an improvement in their symptoms,
patients with mental illness may have concerns and dilemma
about the postdischarge life. They may find their future unclear
and themselves vulnerable. Factors such as the lack of insight,
lack of social support, poor quality of the patient‑doctor
relationship, and mistaken conclusions that the medications
were not needed, and poor awareness about the illness often
contribute to noncompliance to treatment after discharge.[1‑3]
Such noncompliance leads to a worsening of the symptoms;
increased risk of assault, dangerous behavior, and attempted
or completed suicide; more extended hospital stay; high costs;
and decrease in the quality of life and impaired functioning.[1,4]
The juncture of discharge should be considered a significant
event and also an integral part of the treatment process.
Discharge planning is “a formal process that leads to the
development of an ongoing, individualized program of care
and support which meets the objectively assessed needs of
Address for correspondence: Dr. Shahul Ameen,
Department of Psychiatry, St. Thomas Hospital,
Changanassery, Kerala, India.
E‑mail: shahulameen@yahoo.com
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Website:
www.indianjpsychiatry.org
social, cultural, therapeutic, and educational interventions
necessary to safeguard and enhance that person’s health and
well‑being in the community.”[5]
WHAT DOES MHCA 2017 SAY?
Mental Healthcare Act (MHCA) 2017[6] speaks about
discharge planning in the following sections.
Section 98.1
“Whenever a person undergoing treatment for mental illness
in a mental health establishment (MHE) is to be discharged
into the community or to a different MHE or where a new
psychiatrist is to take responsibility of the person’s care
and treatment, the psychiatrist who has been responsible
for the person’s care and treatment shall consult with the
person with mental illness, the nominated representative,
the family member or caregiver with whom the person with
mental illness shall reside on discharge from the hospital,
the psychiatrist expected to be responsible for the person’s
care and treatment in future, and such other persons as may
be appropriate, as to what treatment or services would be
appropriate for the person.”
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DOI:
How to cite this article: Gowda M, Gajera G, Srinivasa P,
Ameen S. Discharge planning and Mental Healthcare Act
10.4103/psychiatry.IndianJPsychiatry_72_19
2017. Indian J Psychiatry 2019;61:S706-9.

S706 © 2019 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

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Gowda, et al.: Discharge planning in MHCA
Section 98.2
“The psychiatrist responsible for the person’s care shall in
consultation with the person above referred, ensure that a
plan is developed as to how treatment or services shall be
provided to the person with mental illness.”
Section 98.3
“The discharge planning under this section shall apply to
all discharges (under section 86, 87, 89, 90) from a MHE.”
Thus, MHCA specifies that the treating psychiatrist should
decide, in consultation with all relevant parties, what
interventions will be needed for a person with mental illness
after the discharge and how those interventions would be
implemented. Moreover, section 98.1 also specifies that
necessary steps have to be taken not only during discharge
but also when the care of the patient is being transferred to
another psychiatrist or when the patient is being transferred
to another MHE. Remember that, during such transfers to
other MHEs, there are other formalities too to be taken care
of as specified in Section 93.1, i.e., “A person with mental
illness admitted to a MHE under section 87 or section 89 or
section 90 or section 103, as the case may be, may subject to
any general or special order of the Board be removed from
such MHE and admitted to another MHE within the State
or with the consent of the Central Authority to any MHE in
any other State: provided that no person with mental illness
admitted to an MHE under an order made in pursuance of an
application made under this Act shall be so removed unless
intimation and reasons for the transfer have been given to the
person with mental illness and his nominated representative.”
WHY THESE CLAUSES?
India enacted MHCA 2017 as a consequence of it being a
signatory to the United Nations Convention on the Rights
of Persons with Disabilities (UNCRPD). The above clauses
in MHCA regarding discharge planning are in line with the
right of the mentally ill to live independently and in the
community as stated in the UNCRPD.[7] For the first time,
discharge planning has been mandated by the law and
treating team is made responsible and liable. Moreover, we
should remember that even if MHCA or UNCRPD were not
there, sound clinical practice automatically entails preparing
a discharge plan for ongoing care and rehabilitation of
the patient. Research has shown that psychiatric patients
who receive adequate discharge planning are more likely
to utilize the outpatient services, less likely to become
socially isolated, and less likely to require immediate
rehospitalization.[8‑10]
Against this background, we searched for available literature
on the practical aspects of designing and implementing an
adequate discharge plan. This article summarizes the major
findings.
Indian Journal of Psychiatry Volume 61 (Supplement 4), April 2019
AIMS OF DISCHARGE PLANNING
Discharge planning should be done with multiple aims in
mind, the major ones being:
• Assisting with re‑entry to the community
• Providing the support needed to sustain the progress
that was achieved during the in‑patient care
• Achieving continuity and coordination of care and
treatment
• Providing and mobilizing a level of support that
corresponds to what the patient would need for
community living
• Minimizing the chances of relapse or immediate return
to the hospital
• Preventing homelessness, suicide and/or being
criminalized
• Ensuring early intervention during crisis and relapse
• Optimal health and well‑being of the patient.[5]
ASSESSMENT
For the discharge planning to be effective, an assessment of
the specific needs of that particular patient should be first
performed. Some domains that need attention during the
assessment include:
• Capacity for self‑care: assess the patient’s capacity, insight,
and perception toward the psychiatric illness. This will
help us understand their current levels of functioning and
the potential need for support and assistance. Frequent
assessment of the symptoms during the inpatient stay
will help in knowing whether the illness is responding to
the treatment and in recognizing chances of self‑harm or
aggressiveness in the immediate postdischarge period.
Assess whether the patient has the resources and ability
to access the medications that are being prescribed and
to travel for the follow‑up appointments. This is especially
important as difficult to travel is a major reason for
nonadherence.[11] Furthermore, assess what all strengths
the patient has that would help him/her in future in
handling the illness and the various aspects of its treatment
• Clinical needs: identify the potential predisposing
factors that can lead to distress or relapse. The patient
should be informed about the importance of sleep
hygiene, nutrition, lifestyle modification, anticipated
adverse effects of the medication, and duration of
treatment. Appraise the patient about the early warning
signs and teach them appropriate techniques to cope
with those factors and instruct them to immediately
come for follow‑up whenever such factors become too
severe to handle on their own. Furthermore, assess the
family’s understanding of the illness and its treatment
and the family’s needs related to the illness. Identify the
immediate caregiver who can manage the emergency
• Other needs: assess domains such as socioeconomic,
cultural, and spiritual. Discuss where the patient would
stay after the discharge: the levels of support available
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Gowda, et al.: Discharge planning in MHCA
and needed, the wishes and decisions of the patient
and the family, and the recommendations if any the
treating team has in this regard should be taken into
account, and a consensus arrived at through discussions
between all the relevant parties.[5,12]
For each area of identified need, a statement should be made
about the service to be provided or the action to be taken.
INVOLVE THE FAMILY
It is essential to keep the patient’s family in the loop,
especially in closed ward settings where the patient is
admitted without any bystanders. The patient’s progress
during the hospital stay and how ready they are for discharge
should be periodically discussed with the family. One study
pointed out that satisfaction in discharge planning drops
when there is no contact between the staff and the family
regarding discharge.[13] Discharge planning meeting(s), in
which the patient and carers also take part and reveal their
views, is another useful step. The date of discharge can be
planned as per the convenience of both the patient and the
caregivers. A study found that a higher percentage of patients
who took part in collaborative discharge planning meetings
became involved in aftercare services compared to those who
did not attend such meetings.[14] Expressed emotion from the
caregiver should be handled carefully and they should be
encouraged to facilitate the support and care which can lead
to positive outcome during the community living.
ARRANGING OTHER SERVICES
Community services available near the person’s area can
be utilized for crisis management, supervision, support,
compliance check, etc. We should evaluate such services
and examine which ones will best match the particular
needs of a specific patient. Help should be provided to the
patient and the family to establish initial contact with such
services. We can also share help‑line numbers for police,
law, hospital, emergency contact, suicide prevention, etc.
If necessary, community‑based services such as half‑way
homes and group homes should be recommended to the
patient if they are available, as they can provide sufficient
care and support required during the period of transition
to community living. Patients may also require a referral
for medical care for medical comorbidities. Support groups
such as alcoholics anonymous, narcotics anonymous,
al‑anon, schizophrenia group, and other self‑help groups
can assist the patient to sustain the recovery, and details of
such organizations may be provided to patients and family.
Patients should also be informed about relevant government
policies and programs and prevailing benefits. Medical
certificate and other required documentation should be
provided to the patient for referral.
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SOME ESSENTIAL STEPS
Discharge planning should begin immediately after admission
and be updated throughout the inpatient stay.[15] We should
ensure that the discharge plan sufficiently addresses the
practical and social reasons that influenced the admission.
For example if a schizophrenia patient has been re‑admitted
due to relapse following medication noncompliance since he
is living alone, or if a female patient with severe depression
has a husband who suffers from alcoholism, such issues
should be addressed during the discharge planning.
ADDRESSING THE RIGHTS OF A PERSON WITH
MENTAL ILLNESS
We should attempt to educate the patient about the
changes in the mental health act. The discussion should
include the planning of an advance directive and nominated
representative. They should also be informed about the
rights of a person who has a mental illness: specifically, the
right to confidentiality, the right to access medical records,
and the right to legal aid. Clarification about the release of
medical records and its restriction should also be considered,
when applicable. They should be aware of the Mental Health
Review Board (MHRB), its function, and its involvement at the
levels of admission, discharge, authorization for the advance
directive, nominated representative, raising a query, etc.[16]
LEAVE OF ABSENCE
Section 91 of MHCA 2017 mentions that the person can
be given “leave of absence” from the MHE subject to such
conditions if any, and for such duration as such medical
officer or psychiatrist may consider necessary. Leave can
be utilized as a step ahead of discharge for admission
under section 87, 89, and 90. We can stress upon the
issues related to noncompliance, aggression, impulsivity,
and other reasons which leads to the admission. It is
an observation period, where the family can note the
improvement and the responsibilities performed by the
patient. In the absence of community treatment option in
MHCA, this provision can be considered to ensure that the
goal of the treatment and admission are achieved in the
community as well.
DOCUMENTATION
In the era of MHCA, documentation of all clinical decisions
and actions is extremely important, and this applies to
discharge planning too. At the time of discharge, the
patient should be given a copy of the completed discharge
instructions that include recovery goals, possible relapse
signs, ways to deal with them, and the details of whom to
contact in case of emergency. It should contain the name of
the patient and signature of the treating psychiatrist so that
it will not look like a “generic” plan but one customized for
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Gowda, et al.: Discharge planning in MHCA
the particular patient. A copy of the discharge instructions
should be stored in the patient’s file as well as sent to
everyone involved in providing support to the person after
discharge, with documented authorization for release
of information. The medical records should also contain
documentation about the patients’ cognitive intactness and
the capacity for mental illness related decision. It should
also be documented that the patient understands and
agrees with the discharge plan, including the medications
and the follow‑up details.[15] It would be a good practice to
use the regional language wherever applicable.
As a part of the obligation under MHCA 2017, chapter 3,
section 10, the treating team should propose for planning
advance directive, nominated representative, and document
his/her understanding about illness and need for medication.
It should include the measure to be taken in case of relapse
and noncompliance to medications. The patient should be
educated about the various treatment options such as oral
and injectable medication, electroconvulsive therapy, repeated
transcranial magnetic stimulation, deep brain stimulation,
and psychotherapy and their preferences should be enquired
about. Furthermore, preauthorization for proxy consultation
will help the clinician to identify the caregiver for future
reference. This would ease the follow‑up procedure and
maintaining compliance for the patient as well as the caregiver.
The grievances faced by the patient and caregiver should be
addressed and directed to the MHRB whenever necessary.
Routine use of any of the available checklists would ensure that
no points are missed, especially in busy settings. The options
include discharge knowledge assessment tool,[17] discharge
checklist,[18] patient activation assessment form,[19] hospital
discharge checklist,[20] and taking care of myself guide.[21]
SOME LIMITATIONS
MHCA 2017 mandates the discharge planning to be done
before any discharge from an MHE. For a few cases such
as immediate voluntary discharge, disagreement of the
treatment plan, an absence of capacity to consent for
psychiatric illness, discharge against medical advice or
other emergency condition, adequate planning may not
be possible. Rather, these are the situations which require
maximum planning and support, leading to a more grievous
condition. Furthermore, insufficiency of community
psychiatric services and care homes limit the possibilities of
providing community support following discharge.
CONCLUSION
Discharge planning is a mandatory procedure as per the
MHCA 2017. We could use this opportunity to verify and
document the goal set at the time of admission and target
achieved at the time of discharge. It can be a patient‑friendly
and highly practical approach to guide them and improve
their quality of life and mental health in the community. It
Indian Journal of Psychiatry Volume 61 (Supplement 4), April 2019
can also reduce the burden of family and caregiver. Thus,
proper discharge planning can improve the outcome and
prognosis of the person with mental illness.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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