Individuals with serious mental illness transitioning from inpatient to community-based care are at high risk for adverse outcomes including relapse and readmission, homelessness, violent behavior, criminal justice involvement, and suicide. These risks are especially concerning given that 40-60% of patients fail to receive outpatient psychiatric treatment within 30 days of hospital discharge. Many hospital and service system initiatives now identify care transitions and readmissions as key quality outcomes. This presentation reviews the impact of routine discharge planning practices (timely scheduling of appointments, communication between inpatient and outpatient teams) as well as more intensive care management approaches on care transition and readmission outcomes. We also review strategies for implementing intensive care management services including critical time intervention, peer supports, health homes, and team-based community support programs.
This course material was developed by SMI Adviser. Please be aware that some external resources and links referenced within this material may no longer be active or available.
Learning Objectives
- Summarize rates of failed care transitions, readmissions, and other adverse outcomes in the period immediately following discharge from hospital psychiatric inpatient care for individuals with serious mental illness;
- Describe the prevalence and impact on transitions from inpatient to community-based care of routine discharge planning activities including communication between inpatient and outpatient teams, timely scheduling of aftercare appointments, and forwarding treatment summaries to aftercare providers
- Identify approaches to intensive care management interventions that support care transitions and decrease readmission rates.
Target Audience
Counselor, psychiatrist, psychologist, physician (non-psychiatric), physician assistant, nurse/nurse practitioner, peer support/peer specialist
Instructional Level
Intermediate
Estimated Time to Complete
Estimated Duration: 1.0 hours
Program Start Date: July 30, 2025
Program End Date: July 30, 2028
Ongoing Interdisciplinary Discussion Board
After completing the course, engage with colleagues in the mental health field through SMI Adviser's Webinar Roundtable Topics discussion board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. Access through the discussion tab.
How to Earn Credit
Participants who wish to earn AMA PRA Category 1 Credit™, CE credit for psychologists, or a certificate of participation may do so by completing all sections of the course, including the evaluation. A multiple choice quiz is provided based on the content. A passing score of 75% must be achieved. Retakes are available for the test. After evaluating the program, course participants will be provided with an opportunity to claim hours of participation and print an official CME certificate (physicians), CE certificate (psychologists), or certificate of participation (other disciplines) showing the completion date and hours earned.
Continuing Education Credit
Physicians
The American Psychiatric Association (APA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The APA designates this enduring course for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Psychologists
The American Psychiatric Association is approved by the American Psychological Association to sponsor continuing education for psychologists. American Psychiatric Association maintains responsibility for this program and its content.
Continuing education requirements vary from state to state. Many state boards grant reciprocity with national accrediting organizations and other state boards. It is the responsibility of each professional to understand the requirements for license renewal or check with the state or national licensing board and/or professional organization to become more familiar with their policies for acceptable continuing education credit. Social workers and Psychologists should contact their regulatory board to determine course approval.
Faculty and Planner Disclosures
Instructor
- Thomas Smith, MD, is is Chief Medical Officer, New York State Office of Mental Health (NYS OMH); Co-Director, NYS OMH Center for Behavioral Health Integrated Performance Measurement, and Special Lecturer in the Department of Psychiatry at Columbia University. He oversees clinical and quality aspects of the New York State public mental health system with a focus on improving access to prevention, recovery and rehabilitation services for persons with serious mental illness (SMI). Dr. Smith reports no financial relationships with commercial interests.
Planners
- Teri Brister, PhD, LPC, National Alliance on Mental Illness. Reports no financial relationships with commercial interests.
- Amy N. Cohen, PhD, American Psychiatric Association. Reports no financial relationships with commercial interests.
- Tristan Gorrindo, MD, American Psychiatric Association. Reports no financial relationships with commercial interests.
Reviewers
- John Torous, MD, Beth Israel Deaconess Medical Center. Dr. Torous has no relevant financial relationships to disclose. (Reviewed on 6/4/2023)
- Teri Brister, PhD, LPC, National Alliance on Mental Illness. Reports no financial relationships with commercial interests. (Reviewed on 6/6/2023)
- Amy N. Cohen, PhD, American Psychiatric Association. Reports no financial relationships with commercial interests. (Reviewed on 6/5/2023)
Accessibility for Participants with Disabilities
The American Psychiatric Association is committed to ensuring accessibility of its website to people with disabilities. If you have trouble accessing any of APA’s online resources, please contact us at 202-559-3900 for assistance.
Technical Requirements
This internet-based CME activity is best experienced using any of the following:
- The latest and 2nd latest public versions of Google Chrome, Mozilla Firefox, or Safari
- Internet Explorer 11+
This Web site requires that JavaScript and session cookies be enabled. Certain activities may require additional software to view multimedia, presentation, or printable versions of the content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Adobe Acrobat Reader, Microsoft PowerPoint, and Windows Media Player.
Optimal System Configuration:
- Browser: Google Chrome (latest and 2nd latest version), Safari (latest and 2nd latest version), Internet Explorer 11.0+, Firefox (latest and 2nd latest version), or Microsoft Edge (latest and 2nd latest version)
- Operating System: Windows versions 8.1+, Mac OS X 10.5 (Leopard) +, Android (latest and 2nd latest version), or iOS/iPad OS (latest and 2nd latest version)
- Internet Connection: 1 Mbps or higher
Minimum Requirements:
- Windows PC: Windows 8.1 or higher; 1 GB (for 32-bit)/2 GB (for 64-bit) or higher RAM; Microsoft DirectX 9 graphics device with WDDM driver; audio playback with speakers for programs with video content
- Macintosh: Mac OS X 10.5 or higher with latest updates installed; Intel, PowerPC G5, or PowerPC G4 (867MHz or faster) processor; 512 MB or higher RAM; audio playback with speakers for programs with video content
For assistance: Contact educme@psych.org for questions about this activity | Contact support@SMICalAdviser.org for technical assistance