Transitions of Care

Transitions must be well coordinated to help avert hospitalizations, including sophisticated discharge planning and execution

Primary market research with psychiatrists practicing in the hospital setting revealed that discharge planning and follow-through are key in aligning with mental health quality metrics1

Key factors to consider when planning for discharge, begins during the admission phase, and includes addressing the following:1

  • What type of setting will the patient be discharged to?
  • What kind of care support or supervision will the patient need?
  • What type of insurance coverage and access to medications does the patient have?
  • What is the patient’s medication history?

Inpatient education, support, and care coordination objectives2

  • Providing patients with education, support and care coordination while they are in the hospital may help them when they return to the outpatient setting
  • Identifying and helping to reduce barriers to medication adherence can be supported by communicating discharge plans and treatment goals with the patient’s outpatient clinicians
  • In addition, coordinating discharge plan and goals with allied health care partners, aftercare services, and community resources will further help ensure care continuity

Collaboration among multiple entities is needed to meet the emerging challenges around transitions of care for complex clinical pathways

LTACH=Long-term acute care hospital

  • Discharges from the acute care setting to the long-term care setting increased from 21% in 2000 to 26.3% in 20153
  • Jenks et al estimates that about 20% of all Medicare beneficiaries discharged from the hospital are readmitted within 30 days4
  • The national rate of hospital readmissions at 30 days from skilled nursing facilities (SNF) is 21%5
  • SNFs are experiencing shorter stays and falling occupancies6
    • From 2012 to 2017, nursing home occupancies fell from nearly 86% to less than 82%6


  1. Data on file. Adelphi market research. Bipolar Disorder Institutional Patient Journey. September 2015.
  2. Steffen S, Kösters M, Becker T, Puschner B. Discharge planning in mental health care: a systematic review of the recent literature. Acta Psychiatr Scand. 2009;120:1-9.
  3. Werner RM, Konetzka RT. Trends in post–acute care use among Medicare beneficiaries: 2000 to 2015. JAMA Research Letter. 17 April, 2018. JAMA. 2018;319:1616-1617.
  4. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-1428.
  5. Fry L. High acuity unit in SNF: Novel program to improve quality of care for post-acute patients. JAMDA. 2018;19:B18.
  6. McKnight’s Long-Term Care News. Accessed April 24, 2019.