Abstract
Background: A national Department of Veterans Affairs (VA) mental health (MH) quality metric tracks engagement in outpatient MH care after discharge from residential and inpatient settings, with recommendations for 2 or more visits 30 days postdischarge.
Local Problem: A gap in transitioning patients from residential to outpatient MH care was identified at this site.
Methods: A transition management process was developed and piloted, including a new MH Discharge Consult and an RN Transition Care Managers team.
Interventions: Transition Care Managers triaged Discharge Consults, communicated with schedulers and patients pre- and postdischarge, and tracked MH engagement for 30 days postdischarge. Process, outcome, and balancing measures were developed and iteratively adjusted using Plan-Do-Study-Act (PDSA) cycles.
Results: Over 55 weeks, 443 Discharge Consults were placed. There was an average 89% success rate in connecting patients with 2 or more MH visits versus 53% preintervention.
Conclusions: This pilot showed promising results in improving postdischarge MH engagement with the use of PDSA cycles to collect data and refine processes.