Follow-up after hospitalization for mental illness
If you have patients recently discharged from an acute inpatient stay or ER visit related to mental health or substance use disorders, you can help ensure they receive much-needed support during a vulnerable time by scheduling a follow-up appointment within seven days. These follow-ups help prevent medication interruption and decrease the likelihood 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:
- Begin follow-up planning at the time of an inpatient admission or ER visit.
- Encourage your patients to sign a release of information for better communication between various providers.
- Implement regular discussions with patients so they understand the importance of outpatient provider visits and the follow-up plan.
- If your patient signs a release, talk with their family or support system, so they understand the discharge plan and the importance of keeping aftercare appointments.
- Provide a checklist to the patient and their family members with “next steps” after discharge.
- Let the hospital staff know about your patient’s discharge needs and any barriers so they can help if needed.
- Tell office staff/schedulers that it’s extremely important that the patient have an appointment within seven days of discharge.
- Make sure you have accurate post-discharge contact and follow-up information and call your patient to remind them of the appointment.
- Follow up with your patient to make sure appointments were kept. If not, try to reschedule as soon as possible.
- For mental health and substance use follow-ups, grow your community relationships, particularly between the facility and community resources to ensure access. You can also offer telehealth options for patients in rural areas or those with transportation issues.
Provider Resources
