Follow-up after hospitalization for mental illness
Patients recently discharged from an inpatient stay or ER visit for mental illness or substance use disorders are at increased risk during the transition to outpatient care. Scheduling a follow-up appointment within seven days improves continuity of care, supports medication adherence and reduces the risk of readmission.
Patient population: Patients ages 6 and older who were hospitalized for mental illness.
Quality Goal: Make sure patients get timely follow-up care with a mental health practitioner:
- Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health provider within seven days of discharge.
Follow-up after emergency department visit for mental illness
Patient population: Patients ages 6 and older who were in the ER for mental illness and weren’t admitted for an inpatient stay.
Quality Goal: Make sure patients get timely follow-up care with any practitioner:
- Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner with a principal diagnosis of mental illness within seven days of discharge.
Follow-up after emergency department visit for alcohol and other drug abuse or dependence
Patient population: Patients ages 13 and older who were in the ER for alcohol or other drug abuse or dependence (AOD) and weren’t admitted for an inpatient stay.
Quality Goal: Make sure patients get timely follow-up care with any practitioner:
- Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with any practitioner with a principal diagnosis of AOD within seven days of discharge.
Follow-up after high intensity care for substance use disorder
Patient population: Patients ages 13 and older who had an acute inpatient hospitalization, residential treatment or detoxification visit for a diagnosis of substance use disorder.
Quality Goal: Make sure patients get timely follow-up care with any practitioner:
- Schedule an outpatient visit, intensive outpatient encounter or partial hospitalization with any practitioner with a principal diagnosis of substance use disorder within seven days of discharge.
What you can do for your patients
Getting patients to keep their follow-up appointments is a challenge for many providers. Here are some best practices that can help you create a cultural commitment to successful discharge appointments:
- Start follow-up planning during the inpatient admission or ER visit.
Encourage releases of information to support care coordination.
Educate patients and caregivers on discharge plans and the importance of outpatient follow-up.
Prioritize scheduling a follow-up appointment within seven days of discharge.
Confirm post-discharge contact information and use reminders to reduce missed visits.
Track whether follow-up visits were completed and promptly reschedule any missed visits.
Leverage community partnerships and telehealth to improve access to care.
Provider Resources
