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

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The document is about a webinar hosted by the American Psychiatric Association focusing on care transition interventions for patients with serious mental illness (SMI) to decrease hospital readmissions. It highlights the challenges and strategies associated with transitioning patients from inpatient to community-based psychiatric care.<br /><br />The webinar targets medical professionals, providing continuing education credits for participation. The learning objectives include understanding the risks and issues linked to failed care transitions, including the high rates of non-attendance at post-discharge outpatient appointments, readmissions, and adverse outcomes like homelessness and suicide.<br /><br />The presentation notes that routine discharge planning, which involves communicating with outpatient providers and scheduling timely follow-up appointments, is crucial yet inconsistently applied, with only 50% of patients receiving comprehensive planning post-hospitalization. The success rates of follow-up care are low, with only 36% to 71% of patients attending follow-up appointments, depending on the healthcare system.<br /><br />The webinar discusses various models of care that have shown effective results in reducing readmissions, such as the Transitional Care Model, Project RED, and Critical Time Intervention. Furthermore, the need for intensive care management for individuals who have serious mental illness is emphasized, requiring experienced care managers who understand the complexities of SMI and are familiar with behavioral health systems.<br /><br />Finally, the document outlines different intervention models, including Health Homes and Assertive Community Treatment, designed to support better care transitions and improve engagement in outpatient care, addressing both medical and social needs to promote recovery and reduce readmission rates.

Keywords

care transition interventions

serious mental illness

hospital readmissions

American Psychiatric Association

inpatient to community care

continuing education credits

discharge planning

Transitional Care Model

Assertive Community Treatment

behavioral health systems