When is it appropriate to discharge a psychiatric patient from a long-term care facility during psych rounding?

When to Discharge ("Pink Slip") a Psychiatric Patient from Long-Term Care

Discharge a psychiatric patient from long-term care when they have achieved clinical stabilization, no longer require the intensive level of care provided by the facility, have adequate community support systems in place, and appropriate outpatient follow-up has been arranged. This decision should never be based solely on administrative pressure or bed availability.

Core Discharge Criteria

Clinical Stabilization Requirements

• Psychiatric symptoms must be adequately controlled such that the patient no longer poses imminent danger to self or others and can function at a level appropriate for a less restrictive setting 1
• Evaluate the severity of existing suicidal ideation and intent as a primary determinant of readiness for discharge 1
• Avoid implicit coercion such as telling patients they won't be discharged until they state they're not suicidal, as this encourages deceit and impairs therapeutic alliance 1

Functional Assessment

• Assess daily living skills and ability to manage in the planned discharge setting - patients with major deficits in daily living skills may require more supervised community placements rather than immediate discharge 2
• Evaluate whether the patient can be contained in a supportive home or residential setting if considering step-down to partial hospitalization or community care 1

Mandatory Pre-Discharge Requirements

Psychiatric Evaluation

• Psychiatric evaluation is mandatory before hospital discharge in all cases 1
• Screen for mental health needs, substance use disorders, and social support systems before any discharge decision 3

Safety Planning and Risk Assessment

• Conduct a comprehensive safety planning discussion that includes:
  • Identification of warning signs and triggers for symptom recurrence 1
  • Coping strategies the patient can use if symptoms return 1
  • Healthy activities for distraction 1
  • Responsible social supports to contact 1
  • Professional contact information and emergency access instructions 1
  • Means restriction counseling - specifically address securing knives, locking medications, and removing/securing firearms 1

Discharge Environment Assessment

• Verify there is sufficient support at home and someone who can take action if the patient's behavior or mood deteriorates 1
• Never discharge without the caretaker having verified the patient's account and being present for discharge planning 1
• Ensure the family understands how to secure firearms and lethal medications - parents often underestimate children's ability to access firearms, and simply having a gun in the home doubles youth suicide risk 1
• Discuss limiting access to alcohol or disinhibiting substances with both patient and family 1

Follow-Up Care Arrangements

Outpatient Continuity

• Arrange immediate psychiatric follow-up, ideally within 48 hours of discharge 3
• Offer definite, closely spaced follow-up appointments to improve treatment compliance 1
• Be flexible in arranging crisis appointments and remind families by phone or note about appointments 1
• If an appointment is missed, contact the patient and family immediately 1

Alternative Discharge Options

• Consider partial hospitalization, intensive outpatient services, or in-home crisis stabilization as step-down alternatives when patients need more than routine outpatient care but don't require full hospitalization 1
• Partial hospitalization can be appropriate if the patient is disturbed but containable in a supportive setting and provides more time to stabilize and address environmental stresses 1

Special Considerations for Long-Term Care Settings

Community Placement Planning

• Discharged long-stay patients typically require highly supervised community settings including professionally supervised group homes, supervised hostels, or foster families 2
• Over half of long-stay patients can be moved to supervised settings immediately or after 1-2 years preparation in a discharge unit 2
• About 25% of long-stay patients require intensive, individualized rehabilitation targeting engagement, psychotic symptoms, withdrawal, and dangerous behaviors before discharge 2

Quality of Discharge Environment

• Community settings should provide better quality of environment than the hospital - this is a measurable outcome that supports appropriate discharge 4
• Collaborative working and discharge planning are essential for successful early discharge 5

Critical Pitfalls to Avoid

• Never discharge based solely on medical stability without psychiatric clearance - this is inappropriate and dangerous in psychiatric cases 3
• Do not rely on "no-suicide contracts" as a substitute for comprehensive safety planning - these should only be adjuncts for low-intent patients who understand the commitment 1
• Avoid discharging patients to unstaffed accommodation in socially deprived areas - this is a specific risk factor for readmission, particularly for young men with florid psychosis 1
• Do not discharge without addressing family dysfunction or parental psychiatric illness as these factors significantly impact outpatient success 1

High-Risk Readmission Factors

• Young men with florid psychosis, multiple previous admissions, and discharge to unstaffed accommodation are at highest readmission risk 1
• The greatest risk of suicide reattempt is in the months after initial attempt - emphasize consistent follow-up during this vulnerable period 1