Care Transition Interventions That Facilitate Connections With Community Providers And Decrease Hospital Readmissions-Lecture Presentation

Video Transcription

Video Summary

In this video, Dr. Thomas Smith discusses the importance of care transition interventions for individuals with serious mental illness (SMI) who are transitioning from inpatient to community-based care. He highlights the high risk period for these individuals following discharge and the potential adverse outcomes they may face, such as lack of engagement in care, increased risk for homelessness, criminal justice involvement, violent behavior, and suicide. Dr. Smith emphasizes the need for routine discharge planning, which includes communication between providers, scheduling appointments, and forwarding discharge summaries. However, he notes that only 50% of individuals with SMI receive comprehensive discharge planning, and only half attend an aftercare visit within 30 days of discharge. He discusses the impact of routine discharge planning on patients' attendance at visits, highlighting the importance of scheduling appointments. Dr. Smith also explores the challenges and potential solutions for individuals who may need more than routine discharge planning. He discusses care transition models, such as health homes, the critical time intervention model, assertive community treatment (ACT) , and the opening doors to recovery model. Dr. Smith encourages clinicians to utilize these resources and work towards improving care transitions for individuals with SMI. The video was hosted by Amy Cohen, Associate Director for SMI Advisor, and a clinical psychologist. Dr. Smith is credited as the faculty for the webinar.

Keywords

care transition interventions

serious mental illness

inpatient care

community-based care

discharge planning

engagement in care

aftercare visit

care transition models