Background and Aims: Transitions from inpatient and residential mental health (MH) treatment to outpatient MH care represent a high-risk period for patients, who are vulnerable to higher suicide risk, care attrition, and re-admissions.  Recognizing these risks, VA developed quality metrics tracking MH encounters post-discharge, with recommendations for 2- 4 visits in the 30 days following VA residential or inpatient MH discharges, respectively.  The primary aim of this effort was to develop and pilot a transition management process for patients discharged from VA residential care at Greater Los Angeles VA (GLA), starting January 2020, to enhance outpatient MH engagement.

 Methods: A multi-disciplinary team developed a new transition management process, piloting in the residential MH care population.  Prior to launch, a new one-stop “Mental Health Discharge Consult” was developed, removing the need for discharging providers to select from a large menu of subspecialty MH consults.  This consult was paired with a new RN Transition Care Managers team (2 RNs) from the existing workforce with nuanced knowledge of all outpatient MH services.  The transition care managers triaged discharge consults, communicated with schedulers, called patients for appointment reminders or problem-solving as necessary, and monitored charts for 30 days post-discharge.  Process, outcome, and balancing measures were developed with weekly huddles to review data and iteratively adjust. 

 Results: Over 46 weeks, 352 post-discharge consults were placed.  Forty-one weeks of post-30-day data show an average 88% biweekly success rate in connecting patients with the goal of 2 or more MH visits, versus an average of 53% across the 20 weeks pre-intervention (range 43-83%.)  For patients completing ≥2 mental health encounters, most encounters occurred face-to-face.  The RN team successfully connected patients with 20 different MH clinics within GLA.  The team reviewed data weekly to make targeted improvements, eg. identifying providers not placing the discharge consult and contacting them to encourage use. 

 Implications for practice/policy:  This pilot in a complex health system showed promising results in improving post-discharge mental health engagement.  The use of PDSA cycles to collect data and refine efforts has been a key component of success.