Care Transition Interventions that Facilitate Connections with Community Providers and Decrease Hospital Readmissions-View Presentation

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Video Summary

The webinar, "Care Transition Interventions that Facilitate Connections with Community Providers and Decrease Hospital Readmissions," is led by Dr. Thomas Smith, the Chief Medical Officer for the New York State Office of Mental Health. The session addresses the critical period following hospital discharge, highlighting the risk of readmission and other adverse outcomes for patients with serious mental illness (SMI). Dr. Smith emphasizes the importance of routine discharge planning, which includes scheduling appointments, forwarding discharge summaries, and communication between providers. Despite its effectiveness, only about 50% of patients receive comprehensive discharge planning, leading to considerable challenges, including a lack of follow-up care within 30 days post-discharge, which remains at a high rate. <br /><br />The session explores various strategies to improve care transitions and reduce hospital readmissions, especially for high-risk patients. Evidence suggests routine discharge planning activities can significantly increase follow-up appointment attendance, even among high-risk individuals. However, many patients require more than what routine planning offers. Intensive interventions such as the Critical Time Intervention model, Assertive Community Treatment, health homes, and others are discussed as effective resources to enhance care transitions. <br /><br />Barriers such as confidentiality concerns, the need for better alignment in care provider incentives, and a lack of cohesive information sharing between inpatient and community-based providers are acknowledged challenges in effectively implementing care transition planning. Dr. Smith advocates for value-based payment structures to align incentives and improve collaboration across care settings. Additionally, there is a call for enhancing provider communication and ensuring essential information is relayed to community providers to support the patient's transition to community care post-hospitalization.

Keywords

care transition

hospital readmissions

discharge planning

serious mental illness

Dr. Thomas Smith

Critical Time Intervention

Assertive Community Treatment

value-based payment

provider communication

community providers