Managing Readmissions

Find statistics, mental-health–specific interventions, and management strategies that may help reduce readmissions and optimize the transition of care among psychiatric patients.

Managing Readmissions

Readmission Case Studies

Discharge in Psychiatric Patients and Associated Readmissions

  • In 2011, mood disorders and schizophrenia had the highest number of all-cause-30-day hospital readmissions among adult Medicaid patients.1
  • A 2012 statistical brief examining hospital readmissions involving psychiatric disorders showed hospital stays for mood disorders or schizophrenia were substantially longer than stays for non-mental or substance use disorders and were more likely to be followed by readmission.1
    • Patients admitted for mood disorders were more than twice as likely to return to the hospital within 30 days for the same initial diagnosis compared with those with an initial stay for a non-mental or substance use disorder condition.1
    • For patients with an initial hospital stay with a diagnosis of schizophrenia, the 30-day readmission rate was more than four times higher than for a non-mental or substance use disorder condition.1
  • A longitudinal multi-site study investigated whether comorbid mental illnesses influenced 30-day hospital readmission rates in a national sample including more than 160,000 index hospitalizations for heart failure (HF), acute myocardial infarction (AMI), and pneumonia.2
    • In combination, all-cause readmissions for individuals with any psychiatric diagnosis in the past year were higher than for those with no psychiatric comorbidity (21.7% vs 16.5%).2
    • For individuals originally admitted for any of the three conditions independently (HF, AMI, or pneumonia), those with any psychiatric comorbidity had higher readmission rates than individuals with none (HF 22.9% vs 19%, AMI 12.1% vs 9.2%, pneumonia 20.2% vs 16.2%).2
    • These findings suggest that psychiatric comorbidities influence 30-day-all-cause readmission rates for individuals with HF, AMI, and pneumonia.2



  1. Heslin KC, Weiss AJ. Hospital readmissions involving psychiatric disorders, 2012. Healthcare Cost and Utilization Policy. 2015.
  2. Ahmedani BK, Solberg LI, Copeland LA, et al. Psychiatric comorbidity and 30-day readmissions after hospitalization for heart failure, AMI, and pneumonia. Psychiatr Serv. 2015;66(2):134-140. 

States Reducing Readmissions

See how three states manage readmissions with interventions, programs, and management strategies that are working.



New York

California’s Best Practices Manual for Discharge Planning 

The Best Practices Manual for Discharge Planning: Mental Health & Substance Abuse Facilities, Hospitals, Foster Care, Prisons and Jails was funded by a grant from the California Endowment. 

The manual discusses best practices for discharge planning in four of the institutions with severe shortcomings in Los Angeles: mental health and co-occurring disorder treatment facilities, hospitals, foster care, and jail/prisons. 

The National Health Care for the Homeless Council has outlined six recommendations for providers of mental health, health, and foster care and penal institutions for successful implementation of discharge and aftercare planning: 

  • Plan should prevent consumers from falling into homelessness. 
  • Identification of appropriate housing is critical. Discharging to emergency shelters is inappropriate in any situation. Discharges may be made on a case-by-case basis to homeless programs with 24-hour transitional programs. Discharging to supportive housing or halfway-houses is beneficial. 
  • Plan must be individualized, comprehensive, and coordinated with community-based services. 
  • Consumers must participate in the planning. 
  • Institution staff and community partners should be included in the planning. 
  • Appropriate treatment must be included for consumers who abuse substances. 

Discharge planning for mental health and substance abuse facilities: 

  • The benefits of conducting discharge planning for clients with substance abuse, mental health, or co-occurring issues include: 
    • Linking clients to appropriate next steps 
    • Minimizing likelihood of relapse 
    • Preventing homelessness or criminalization 
    • Assisting clients with re-entry into the community 
  • Discharge planning is important to maintain gains achieved during the course of stay. 
  • Conversely, a lack of discharge planning is a significant obstacle to establishing a stable recovery.
  • Both mental health and substance abuse treatment staff require training to meet the needs of clients with co-occurring disorders.
  • Discharge planning is a team approach and should include the client and, when appropriate, family members.
    • The treatment team, including psychologist, social worker, psychiatrist, counselor, case manager, vocational specialist, and housing professionals, should participate in creation of the discharge plan.
    • The team should also include peers, relatives, and friends of the client.
  • Discharge plans should adhere to the recommendations of the National Health Care for the Homeless Council.
    • Be tailored for different needs of different clients essentially it is important to create an Individual Service/Treatment Plan.
    • Be comprehensive – this means that all the client's needs across multiple health systems should be addressed in the discharge plan.
    • Create a system that is continuous and coordinated.
    • For clients who abuse substances must include appropriate treatment, as such clients are more at risk for homelessness and criminalization.
    • Next step resources are central to discharge planning. Without these resources, discharge planning is illusory.
    • Lack of good discharge planning is often related to lack of appropriate options.
  • The American Association of Community Psychiatrists recommends the following core elements be included in discharge planning:
    • Comprehensiveness
    • Individual engagement
    • Responsiveness to special populations
    • Maximizing resources
    • Relapse prevention
    • Clear responsibilities
    • Contingency plans and tracking
  • Monitoring outcomes


Baron. Best practices manual for discharge planning: mental health & substance abuse facilities, hospitals, foster care, prisons and jails. The California Endowment/Los Angeles Coalition to End Hunger & Homelessness; 2008.


Colorado’s Access Health Colorado Provider Manual 

The 2015 Colorado Access/Access Health Colorado Provider Manual outlines policies, responsibilities, reimbursement, and care management for providers.

  • Upon completion of treatment or agreed discontinuation of treatment, a discharge from services will occur.
  • The discharge planning standards include a discharge summary to ensure continuity of care.
    • The clinical record will include a summary of services provided, the reason for transfer or discharge, member status, progress toward achieving treatment goals, follow-up appointments or referrals, and who and where the member/family may call for additional services if necessary. 
  • Additionally, a Colorado Client Assessment Record is completed upon discharge.
  • Some chart standards include:
    • Consent for psychiatric services
    • Professional disclosure 
    • Notification of specific rights and responsibilities 
    • Authorization to release information 
    • Advance directives 
  • Some assessment standards include:
    • Chief complaint 
    • Psychosocial history and conditions 
    • Cultural factors and considerations 
    • Developmental history for children and adolescents 
    • Psychiatric and medical history 
    • Signed release of information 
    • Mental status evaluation
    • Safety and risk assessment 
    • Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) diagnoses 
  • Some individualized service plan standards include:
    • Specific and measurable goals or objectives 
    • Crisis plans
    • Service plan and assessment updates at least every 6 months
  • Some documentation of active treatment includes:
    • Progress notes 
    • Prescribed medications 
    • Medication reviews at a minimum of every 3 months
    • Preventive services 


Colorado Access/Access Health Colorado. 2015 Provider Manual. Updated January 2015. Accessed May 3, 2018.


New York’s Transition of Behavioral Health Benefit to Recovery Implementation 

The “Transition of Behavioral Health Benefit into Medicaid Managed Care and Health and Recovery Program Implementation” document from the New York State Department of Health provides guidance on the transition of behavioral health benefits to Medicaid managed care.

  • The Personalized Recovery Oriented Services (PROS) is a recovery-oriented program for individuals with severe and persistent mental illness. 
  • It is a person-centered, strength-based model and is comprised of group and individual services designed to assist a participant to overcome mental health barriers. 
  • Any one of the following criteria must be met for discharge: 
    • Member has sustained recovery goals for 6–12 months and a lower level of care is clinically indicated.
    • Member has achieved current recovery goals and can identify no goals that would require additional PROS services.
    • Member is not participating in a recovery plan, is not making progress toward any goals, extensive engagement efforts have been exhausted, and no significant benefit is expected from continued participation.
    • Member can live, learn, work, and socialize in the community with support.
  • Assertive Community Treatment (ACT) is:
    • A specialty behavioral health service delivered to individuals with serious mental illnesses whose needs have not been met by traditional approaches.
    • An evidence-based practice that incorporates treatment, rehabilitation, case management, and support services from a mobile, multi-disciplinary mental health team. 
  • ACT recipients meeting any of the following criteria may be discharged: 
    • Demonstrate, over a period of time, an ability to function in major life roles and can continue to succeed with less intensive service. 
    • Move outside the geographic area of ACT responsibility.
      • The ACT team must transfer mental health service responsibility and maintain contact with the recipient until the recipient is engaged with a provider in the new service arrangement.
    • Need a medical nursing home placement, as determined by physician.
    • Hospitalized or locally incarcerated for 3 months or longer. 
      • An appropriate provision must be made for individuals to return to the ACT program upon release from hospital or incarceration.
    • Request discharge despite best, repeated efforts of engagement. 
      • Alternative treatment must be arranged with special care when the recipient has a history of suicide, assault, or forensic involvement.
      • Lost to follow-up for a period of greater than 3 months despite persistent efforts to locate them, including following all policies and procedures related to reporting individuals as “missing persons.” 
    • For all individuals discharged from ACT to another provider, there is a 3-month transfer period during which recipients who do not adjust well to their new program may voluntarily return to ACT. 
      • During this time, the ACT team must maintain contact with the new provider to support the new provider’s role in the recipient’s recovery and illness management goals.
    • The decision not to take medication is not a sufficient reason for discharging an individual from ACT.
    • If an ACT recipient is under a court order to receive Assisted Outpatient Treatment (AOT), any discharge must be planned in coordination with the county’s AOT program administrator.


New York State Department of Health. Transition of Behavioral Health Benefit into Medicaid Managed Care and Health and Recovery Program Implementation. Published October 2015. Accessed May 3, 2018.

IDEAL Discharge Planning Implementation Handbook

"The goal of the IDEAL Discharge Planning strategy is to engage patients and family members in the transition from hospital to home, with the goal of reducing adverse events and preventable readmissions."

When IDEAL Discharge Planning was implemented in a surgical unit as part of a year-long pilot project, Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey scores trended upward for the 12-month period following implementation, particularly for measures related to discharge and communication with doctors. Hospital leaders viewed the improvements as extremely significant.

The IDEAL Discharge Planning strategy highlights the following elements of discharge planning:

Include the patient and family as full partners in the discharge planning process. 

Discuss with the patient and family five key areas to prevent problems at home:

  1. Describe what life at home will be like
  2. Review medications
  3. Highlight warning signs and problems
  4. Explain test results
  5. Make follow-up appointments

Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps at every opportunity throughout the hospital stay.

Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family, and use teach-back.

Listen to and honor the patient and family’s goals, preferences, observations, and concerns.

The IDEAL Discharge Planning process should also include at least one Planning Discharge Meeting to discuss concerns and questions with the patient, family, and selected members of the discharge team.


Guide to Patient and Family Engagement in Hospital Quality and Safety, 'Strategy 4: Care Transitions from Hospital to Home: IDEAL Discharge Planning.' Agency for Healthcare Research and Quality, Rockville, MD. Originally created June 2013. Accessed May 3,2018.

Tools for the IDEAL Discharge Planning Strategy

Re-Engineered Discharge (RED) Toolkit

Help ensure a smooth and effective transition at discharge

“The Re-Engineered Discharge (RED) consists of a set of 12 mutually reinforcing actions that the hospital undertakes during and after the hospital stay to ensure a smooth and effective transition at discharge."1


A randomized trial using a re-engineered hospital discharge program tested the effects of an intervention designed to minimize hospital utilization after discharge. This study of 749 adults admitted to a large, urban hospital in the United States where patients were randomized to an intervention designed to minimize hospital utilization after discharge or usual care. The primary outcome of the study was the number of emergency department visits and hospitalizations within 30 days of discharge. Participants in the intervention group had a lower rate of hospital utilization than those receiving usual care (0.314 vs 0.451 visits per patient per month; P=0.009). 2

Components of the RED Toolkit include:1

  1. Ascertain need for and obtain language assistance.
  2. Make appointments for follow-up care (eg, medical appointments, post-discharge tests/labs).
  3. Plan for the follow-up of results from tests or labs that are pending at discharge.
  4. Organize post-discharge outpatient services and medical equipment.
  5. Identify the correct medicines and a plan for the patient to obtain them.
  6. Reconcile the discharge plan with national guidelines.
  7. Teach a written discharge plan the patient can understand.
  8. Educate the patient about his or her diagnosis and medicines.
  9. Review with the patients what to do if a problem arises.
  10. Assess the degree of the patient’s understanding of the discharge plan.
  11. Expedite transmission of the discharge summary to clinicians accepting care of the patient.
  12. Provide telephone reinforcement of the discharge plan.


  1. Re-Engineered Discharge (RED) Toolkit. April 2016. Agency for Healthcare Research and Quality, Rockville, MD. Accessed on May 3, 2018.
  2. Jack BW, Chetty VK, Anthony D, et al. A re-engineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):179-197.

Tools for the RED Discharge Planning Strategy

Re-Engineered Discharge (RED) Toolkit. Content last reviewed April 2016. Agency for Healthcare Research and Quality, Rockville, MD.