Abstract
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. A gap in transitioning patients from residential to outpatient MH care was identified at this site. A transition management process was developed and piloted, including a new MH Discharge Consult and an RN Transition Care Managers team. 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. 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. This pilot showed promising results in improving postdischarge MH engagement with the use of PDSA cycles to collect data and refine processes.
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