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  1. Kantaria, Tina MD
  2. Talag, Germiniano RN
  3. Fan, Jia MS
  4. Navarro, Filda RN
  5. Sonza, Patrick RN
  6. Fears, Scott MD, PhD
  7. Yang, Calvin MD, PhD
  8. Balsam, Jeffrey PharmD, BCPS
  9. Birman, Sharon PhD
  10. Lam, Mona PhD
  11. Guze, Barry MD
  12. Raja, Pushpa MD, MSHPM


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.