Care Transition Interventions that Facilitate Connections with Community Providers and Decrease Hospital Readmissions
Resource Availability
This course material was originally created by SMI Adviser, now rebranded as SMI CalAdviser. The content in this course material is still current and relevant, yet, please be aware that some external resources and links may no longer be active or available. 
Overview

Description 

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. 

Format 

Recorded webinar, non-interactive, self-paced distance learning activity with post-test.  

This presentation was recorded on June 4, 2020. 

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. 

Outline 

  • Risks after psychiatric discharge 
  • Standard discharge planning 
  • Effectiveness of routine planning 
  • Intensive care transition model 
  • Models for SMI care transitions 

Target Audience 

Psychiatrist, Physician (Non-Psychiatric), Physician Assistant, Nurse/Nurse Practitioner, Psychologist, Counselor, Peer Support/Peer Specialist 

Instructional Level 

Advanced 

Estimated Time to Complete 

Estimated Duration: 1.0 hours  
Program Start Date: July 30, 2025 
Program End Date: June 30,2028 

Ongoing Interdisciplinary Discussion Board 

After completing the course, engage with colleagues in the mental health field through the 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 

After completing the evaluation, participants will have the opportunity to claim their hours of participation and download the appropriate certificate. Physicians may obtain an official CME certificate, other healthcare professionals may receive a CE certificate (as applicable), and all other attendees may generate a certificate of participation. Each certificate will reflect the event date and total hours earned. 

Continuing Education Credit 

In support of improving patient care, American Psychiatric Association (APA) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.  

Physicians   

The APA designates this live event for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.  

Psychologists   

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. 

 

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 

The American Psychiatric Association adheres to the ACCME's Standards for Integrity and Independence in Accredited Medical Education. Any individuals in a position to control the content of a CME activity - including faculty, planners, reviewers, or others - are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.  

Faculty 

  • 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.  

Program 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 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 

 

 

Summary
Availability:
On-Demand
Expires on Jul 30, 2028
Credit Offered:
1 CME Credit
1 Psychology CE Credit
1 COP Credit
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