The beneficial effects of postdischarge follow-up after inpatient hospitalizations have been documented [Kan CK et al. Soc Psychiatry Psychiatr Epidemiol. 2007], as has increased recidivism from lack of such care after discharge [Llgen MA et al. Psychiatr Serv. 2008].

Using this literature for evidence-based research, Linda I. Kaplan, RN, MSN, and Danielle Battinelli-Weng, RN, BSN, Veterans Affairs New York Harbor Healthcare System (VA NYHHS), Manhattan Campus, New York, New York, USA, presented a poster on a system-wide postdischarge initiative to improve continuity of care.

The 7-day follow-up is a Veterans Health Affairs (VHA) Performance Measure. It involves either seeing patients face-to-face or having in-depth telephone contact with them within 7 days of discharge. VA NYHHS's goal is to ensure continuity of care from the 17 North (17 N) inpatient admission process to the outpatient mental-health setting. This is part of the unit's effort to facilitate engagement and help veterans with psychiatric diagnoses make a successful transition to ongoing treatment in a less restrictive environment.

The VHA benchmark of 75% assures that appropriate interventions can be initiated in a timely manner if veterans clinically deteriorate due to nonadherence to medications and/or their treatment plan, or if they become a danger to themselves or others.

To meet the requirements of the VHA Performance Measure and ensure access to care within 7 days, 17 N adopted a 5-step program. Nursing staff educate patients from admission to discharge on the importance of outpatient follow-up care and the need to return or be contacted within 7 days of discharge. They then ensure that each patient has an active telephone number and is informed that they will be receiving postdischarge phone calls. A new spreadsheet for tracking the initiative was developed and slated for review by staff every day. Social workers on the 17 N unit call patients the day after discharge; if a social worker cannot reach the patient by phone, the case is handed off to the nursing staff, who continue to make calls. Evaluation of compliance with both postdischarge face-to-face provider meetings and telephone contact with patients is tracked on an ongoing basis.

The new procedures, which are best practices at other VHA facilities, were implemented in 2012. By the following fiscal year, VA NYHHS (17 N) exceeded the benchmark for continuity of care with a score of 82%, a 26-point gain over results in 2012 (Figure 1).

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Figure 1.

7-Day Mental Health Postdischarge Follow-Up: Fiscal Years 2012–2014

Reproduced with permission from LI Kaplan, RN, MSN.

This outcome demonstrates the importance of having psychiatric nurses educate and assist patients in adhering to their treatment plans. On the continuum of care, inpatient psychiatric treatment is only the first step toward recovery.