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

Presentation Slides

Pdf Summary

This document is a summary of a webinar on care transition interventions for individuals with serious mental illness (SMI) to decrease hospital readmissions. The webinar was part of the Clinical Support System for Serious Mental Illness (CSS-SMI) initiative, which is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and implemented by the American Psychiatric Association (APA). The webinar highlighted the need for comprehensive routine discharge planning that includes communication with outpatient providers, timely scheduling of aftercare appointments, and forwarding of treatment summaries to aftercare providers. However, it was found that only 50% of discharged individuals with SMI receive comprehensive routine discharge planning. The webinar also discussed the high rates of failed care transitions and readmissions in the period immediately following discharge, as well as the factors that make patients more vulnerable to these adverse outcomes, such as short length of stay, homelessness, and co-occurring chronic medical conditions. Intensive care transition interventions, such as the Transitional Care Model, Project RED, and the Care Transitions Intervention, were discussed as effective approaches to support care transitions and decrease readmission rates. These interventions involve pre-discharge education, post-discharge follow-up, improved communication between inpatient and outpatient clinicians, and outreach following failed appointments. The webinar emphasized the need for further refinement and testing of these interventions to promote their availability. Overall, the goal is to improve routine discharge planning practices and provide intensive care management services to ensure a successful transition from inpatient to community-based care for individuals with SMI.

Keywords

care transition interventions

serious mental illness

hospital readmissions

comprehensive routine discharge planning

readmission rates

Transitional Care Model

Project RED

Care Transitions Intervention

improved communication

intensive care management services