After psychiatric hospital discharge: how to arrange follow-up care

Discharged without a follow-up appointment: who to contact

You do not have to reconstruct the handover alone. Use the names and numbers in your discharge information. If you cannot find it, call the hospital switchboard and ask for the ward you stayed on or the team that organised your discharge.

1. Ask the hospital what was arranged

   Give your discharge date. Ask which service received the referral, whether it accepted it and who is responsible for support before the first appointment. If a call or visit was promised and did not happen, say so.

2. Check the receiving service has the information

   Ask whether it has your referral and discharge summary, your correct phone number and the details needed to book you in. “The referral was sent” and “an appointment is confirmed” describe different stages. Ask which stage you have reached.

3. Make any immediate problem explicit

   For example: “I have nowhere safe to stay”, “I cannot collect my medication”, or “My mental health has got worse since I left”. Ask to speak with a clinician or the appropriate support worker, rather than leaving the concern only as a booking message.

4. Agree what happens if the next step fails

   Write down who you spoke to, what they will do and when you should hear back. Ask whom to contact if that does not happen. If you cannot reach the team, contact your primary care clinician or local urgent mental health service for advice about your current needs.

What to check in your mental health discharge plan

A discharge summary records the hospital stay. A care plan explains what happens next. They may be combined or given different names. Ask someone to go through the information with you and explain anything you cannot use or understand. AHRQ’s discharge guidance emphasises understandable instructions and checking that the person can explain the plan back.

Keep the documents somewhere you can find them, such as a folder or a secure place on your phone. If there are test results still pending, ask who will review them and tell you the outcome. You can request an interpreter or an accessible version of the information.

A message to use when nobody has contacted you

You do not need to explain your whole history in the first message. The purpose is to identify the missing step and get it to the right person. Use the hospital or clinic’s official contact route.

If your situation has become urgent, say that directly and seek clinical advice rather than relying on a routine email. If you miss a call, tell the service the best way and time to reach you. A change of address, a shared phone or no mobile credit can all affect the plan.

What should the first follow-up contact cover?

A call or home visit soon after discharge may be separate from an appointment with a psychiatrist. Ask what each contact is for. AHRQ’s follow-up call guidance covers current health, medication, appointments and difficulties carrying out the discharge plan. It is a care model, not a promise that every hospital offers the same service.

Before the conversation, jot down what has changed since you left: how you are managing day to day, what is worrying you and anything you have been unable to arrange. You might start with: “The plan says I should do this, but here is what is getting in the way.”

Clarify prescriptions before your supply ends

Ask the team to confirm the current medication list and explain any changes made in hospital. If the labels and discharge instructions seem to disagree, ask a pharmacist or prescriber to resolve this; do not choose a dose yourself. Ask who will prescribe next and arrange any monitoring. NIMH advises working with a clinician before stopping or changing psychiatric medication, including when you feel better.

If the immediate problem is that your medicine is running out, use our separate guide to getting help with a psychiatric medication refill. Tell the professional about any missed doses and ask for instructions for your specific medicine.

Follow-up after psychiatric hospital discharge: routes by country

Start with the service that discharged you. A national recommendation or service standard does not confirm that your own appointment is booked. Ask for the actual arrangement, including any costs, transport needs and support before the appointment.

United States: hospital discharge staff and your next provider

Contact the hospital’s discharge planner, social worker or case manager, and the outpatient service listed in your documents. Ask whether the service accepts your insurance, whether any authorisation is needed and what your out-of-pocket cost would be. If the proposed service cannot see you, ask the hospital to help identify another route. SAMHSA’s treatment-finding guidance suggests checking availability, insurance or low-cost options, and whether a provider fits your needs. There is no single appointment deadline established by this guide for every US service.

United Kingdom: confirm the route for your NHS nation

In England, NHS guidance for adult inpatient mental health care says follow-up should be arranged before discharge and occur within 72 hours, excluding specialised services commissioned by NHS England. This contact is usually through a community mental health or crisis resolution and home treatment team; it is not necessarily a psychiatrist appointment. If the agreed contact has not happened, call the team or ward. Check local arrangements in Scotland, Wales and Northern Ireland rather than assuming the English standard applies.

Australia: the hospital team, community service and GP

Ask which community mental health service or clinician is taking over, and whether your GP has received the discharge information. As a state-specific example, NSW Health’s discharge policy requires the receiving community mental health service to contact a person within seven days after discharge from an acute inpatient mental health unit. That is an NSW public-service policy, not a universal deadline for every Australian service. Ask the hospital about the applicable arrangements in your state or territory and whether any private appointments involve a fee.

Canada: your hospital and provincial or territorial services

Ask the hospital which outpatient team or primary care clinician will follow up, whether the referral was accepted and who can help until then. Arrangements vary by province, territory and hospital. In Ontario, CAMH describes a patient-oriented discharge summary covering medicines, appointments, what to expect and community support. Ask whether your hospital provides a similar plain-language summary; the CAMH example does not establish a nationwide service or deadline.

Living somewhere else? Ask your ward for the name of the local service receiving your care and a way to contact it directly. If you were treated away from home or across a border, make the location of your ongoing care explicit.

What if the aftercare plan is hard to follow?

A plan needs to work in your actual life. NICE recommends considering practical needs such as housing, food, transport and finances during mental health discharge planning. Tell the team about a barrier even if it does not sound like a medical issue.

• You cannot afford the appointment or travel: ask the discharge team or social worker what covered, public or local alternatives may be available.
• You cannot make the appointment: contact the service, explain the obstacle and ask to rearrange it with an interim plan if needed.
• You are staying somewhere different: tell the service your current location and a safe way to contact you.
• You cannot manage several calls: ask whether one person can help coordinate them with you.

You can use our guide to free and lower-cost mental health care for further starting points. If there is no ongoing psychiatrist available, the guide to finding care while waiting for a psychiatrist covers that separate problem.

Choose what support from others would help

You might want someone to sit beside you during a call, help organise papers or come to an appointment. Ask for the specific help you want, and tell the service what it may share. Healthdirect describes involving a supporter in discharge planning with the person’s consent. Peer support can offer understanding, while prescribing and treatment decisions remain with qualified professionals.

What if I do not feel ready to leave, or struggle once I am home?

Tell the treating team before discharge what feels unsafe or unmanageable. Ask to discuss the plan with them and, if you want, a supporter or advocate. You can ask: “What support will make this workable, and what should I do if it is not?” For help raising a concern, ask about the hospital’s patient advocacy or liaison service. Review and appeal processes depend on local rules and your circumstances.

Leaving hospital can bring mixed feelings. NICE recognises that transitions in care can evoke strong emotions and calls for planned, coordinated support. Being at home does not mean you have to manage every difficulty alone. If your mental health worsens, tell your care team promptly. If you cannot stay safe, seek urgent help rather than waiting for the next planned appointment.

Your account of what is and is not working matters. For example: “I agreed to the plan on the ward, but at home I cannot manage the travel and I need help changing that.” Asking to review the plan is a concrete way to bring that experience into your care.