Emerging evidence for mental health discharge planning and transfer of care

This report, commissioned by the NSW Ministry of Health, reviews recent evidence and best practice for mental health discharge planning and transfer of care. It combines a rapid review of recent peer-reviewed studies with a desktop review of Australian policies and guidelines.

Key findings highlight that effective discharge relies on early, multidisciplinary planning, strong care coordination, structured communication (including digital tools), and active involvement of families and carers. Interventions like case management, transitional discharge models, and peer support improve continuity of care and short-term outcomes, though evidence for long-term and diverse population impacts is limited.

Best practice in Australia emphasises trauma-informed, person-centred, and culturally safe approaches, especially for Aboriginal and Torres Strait Islander peoples, as well as attention to social determinants like housing. The report calls for more inclusive research and ongoing policy development to ensure safe, effective, and recovery-oriented transitions from inpatient to community mental health care.

van Kemenade C., Schiavuzzi A., Lewis, M. Petrunoff N., Goldberg E. Emerging evidence for mental health discharge planning and transfer of care: an Accelerated Evidence Snapshot and Desktop Review prepared by the Sax Institute (www.saxinstitute.org.au) for the NSW Ministry of Health, 2025. Doi:10.57022/oupk2471