Table 2 Key recommendations across EIPS transition points

Transitioning in to the EIPS

• Acknowledge that this is a challenging time for the young person and their families, which may be because of psychiatric symptoms and functional issues, negative experiences with their previous engagement with the mental health system, stigma, and that the process may feel intrusive.

• Establish strong pathways into the EIPS to ensure transitions from other services are transparent, coordinated and communicated well.

• Where possible include support people in the process.

• Provide a clear overview of the EIPS support and treatment.

• Seek to understand and address the young person and their supporters’ expectations of care and support needs.

• Work towards building trust, rapport and a supportive relationship.

• Use creative engagement strategies that support young people to feel at ease.

• Provide iterative and ongoing communication about the process and what is likely to happen with treatment and support, acknowledging the common challenges and benefits from the outset and that it takes time to adjust.

Transitioning in and out of hospital whilst in EIPS care

• The EIPS involves young people (and where appropriate their support people) in decisions about hospital transitions (entry and discharge).

• EIPS coordination and communication with the hospital system is active and ongoing to maintain a young person’s continuity of care.

• Collaborative discharge planning occurs routinely and includes relapse prevention planning, scheduling follow-up EIPS support, and coordination with other involved parties (support people, and external groups such as school, university, or housing support).

• The EIPS routinely review the prescribed medication after the hospital discharge to assess changes in dosage and check for side effects from any new medications.

Within service changes

• At EIPS commencement, explain to young people and their supporters how the staffing system works (e.g., regular 6 month psychiatry registrar rotations) and the handover process when staff changes occur.

• Minimize staff turnover where possible. This might be done through promotion of better workplace culture, initiatives to reduce staff burnout, workplace funding stability.

• Ensure processes to reduce the impact of staff changes are in place—such as team-based approaches to care coordination, collective case-management, regular team case reviews to ensure team collaboration, and supervision over individual cases.

• If staff turnover must occur, ensure that the young person and their supporters are aware of the change as early as possible, and are included in the decision making prior to the event arising. Best practice recommendations at this time include sufficient provision of information and support, joint handover meetings and maintaining consistency of other team members.

• If a new psychiatrist or registrar commences, they should ensure that any changes to the young person’s medication does not happen abruptly without full consultation and joint decision making taking place.

Service discharge

• The length and scope of service, and pathways to other mental health services in the future, are outlined comprehensively when the young person commences with the program.

• Young people and their support people are included in the discharge planning as early as possible when a young person is approaching EIPS discharge.

• Discharge should be well-planned and coordinated, with communication between EIPS and adult mental health services ensuring that the young person and their support people have optimal continuity of care.