Best Practices In Care Transitions For Individuals With .
Best Practices in Care Transitionsfor Individuals with Suicide Risk:INPATIENT CARE TO OUTPATIENT CARE
NATIONAL STRATEGY FOR SUICIDE PREVENTIONThis report advances goals 8 and 9 of the National Strategy for Suicide Prevention: Goal 8: Promote suicide prevention as a core component of health care services. Goal 9: Promote and implement effective clinical and professional practices for assessing and treating thoseidentified as being at risk for suicidal behaviors.Suggested Citation: National Action Alliance for Suicide Prevention. (2019). Best practices in care transitions forindividuals with suicide risk: Inpatient care to outpatient care. Washington, DC: Education Development Center, Inc.ABOUT THE NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION:The National Action Alliance for Suicide Prevention (Action Alliance) is the public-private partnership working to advancethe National Strategy for Suicide Prevention and reduce the suicide rate 20 percent by 2025. Support for Action Allianceinitiatives comes from the public and private sectors. The Substance Abuse and Mental Health Services Administration(SAMHSA) provides funding to Education Development Center (EDC) to operate and manage the Secretariat for theAction Alliance, which was launched in 2010.This report is supported by the generous contribution ofUniversal Health Services, Inc., Behavioral Health Division.
TABLE OF CONTENTSIntroduction1The Transition from Inpatient to Outpatient Care2Implementing Best Practices2Recommendations for Inpatient Providers3Recommendations for Outpatient Providers8Together We Can Do Better12References14Resources17Contributors20
National Action Alliance for Suicide PreventionIntroductionThe transition from inpatient to outpatient behavioralhealth care is a critical time for patients with a historyof suicide risk and for the health care systems andproviders who serve them. In the month after patientsleave inpatient psychiatric care, their suicide death rateis 300 times higher (in the first week) and 200 timeshigher (in the first month) than the general population’s(Chung et al., 2019). Their suicide risk remains highfor up to three months after discharge (Olfson et al.,2016; Walter et al., 2019) and for some, their elevatedrisk endures after discharge (Chung et al., 2017). In theUnited States, one out of seven people (14.2 percent)who died by suicide had contact with inpatient mentalhealth services in the year before their death (Ahmedaniet al., 2014) and internationally, a recent meta-analysisyielded a higher percentage at 18.3 percent (Walby,Myhre, & Kildahl, 2018).“ Hospitalization is notdesigned to be the onlytreatment that patients needto restore them to wellness.”Inpatient psychiatric care is designed to mitigateimmediate risk, begin treatment, and prepare individualsfor continuing care after hospitalization. Hospitalizationis not designed to be the only treatment that patients needto restore them to wellness. They need follow-on careafter discharge and referrals for outpatient behavioralhealth care. But all too often, patients fall through gaps inthe behavioral health care system (National Committeefor Quality Assurance, 2017), resulting in increasedsuicide risk and potential loss of life.To help health systems and providers close these gapsin care, improve patient experience and outcomes, andprevent suicide deaths, the National Action Alliancefor Suicide Prevention (Action Alliance)—working withhealth care and suicide prevention experts—developedBest Practices in Care Transitions for Individuals withSuicide Risk: Inpatient Care to Outpatient Care. Thisguide does the following: Discusses the challenges in care transitions and theneed for better care practices and care coordinationfrom inpatient to outpatient behavioral health care Presents feasible, evidence-based practicesthat health systems and providers can take toimprove patient connection and safety duringinpatient to outpatient transition, and providesrecommendations specific to both inpatient andoutpatient settingsThe information in this guide builds on current evidenceabout care transitions, as well as recommendations fromthese sources: Recommended Standard Care for People withSuicide Risk: Making Health Care Suicide Safe(National Action Alliance for SuicidePrevention, 2018) The Way Forward: Pathways to Hope, Recovery,and Wellness with Insights from Lived Experience(National Action Alliance for SuicidePrevention, 2014)The Action Alliance is committed to improving patientoutcomes by working with health care system leadersand clinicians to close gaps in transitions of care. Thisreport was developed to help improve and strengthenpatient care and ensure that people at risk for suicidereceive high-quality, evidence-based, continuous carethat supports connection and recovery and ultimatelysaves lives.Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care1
National Action Alliance for Suicide PreventionThe Transition from Inpatient to Outpatient CareInpatient and outpatient providers play importantand yet different roles in the care of individuals withsuicide risk. Inpatient care—which offers medicallysupervised programs in a hospital setting 24 hours aday, 7 days a week, and typically ranges from 48 hoursto 10 days—is designed to mitigate immediate risk,begin treatment, and prepare patients for continuingcare after hospitalization. Outpatient providers, on theother hand, have an ongoing role in providing a widerange of services to help patients move forward towardimproved health and wellness. Ideally, behavioral healthcare is uninterrupted from inpatient to outpatient care.However, according to the HEDIS data set, nearlya third (30.3 percent) of patients do not complete asingle outpatient visit in the first 30 days after inpatientbehavioral health care in the United States (NationalCommittee for Quality Assurance, 2017).The care transition period is challenging for manyreasons. The hospital has discharged the patient andis therefore no longer providing care. The outpatientprovider has not yet seen the patient and therefore isalso not providing care. So, during the care transitionperiod, no one is providing clinical care; inpatientand outpatient organizations have a diffusion ofresponsibility for patient support; families are unsurehow to best help their loved one; and patients areexperiencing increased vulnerability and risk for suicide.As a result, lives are being lost.Implementing Best PracticesBased in scientific research and informed by clinicalpractice, the recommendations in the next sectionare feasible, evidence-based strategies for caring forindividuals with a history of suicide risk during thetransition from inpatient to outpatient care. Thesestrategies can guide inpatient and outpatient providersto actively take steps toward achieving a higher level ofcare before and during the care transition period.Principles that can help guide organizational decisionsand action include these: Work as a collaborative team. Instead ofviewing inpatient and outpatient services as distinctentities, work together as a unified team andactively include both settings in planning for patientcare. Employ a patient-centered approach thatinvolves all providers, the patient, and the familyand natural supports. Working together in tandemhelps patients safely navigate the gap between caresettings and continue the path toward improvedmental health and wellness. Cultivate human connection. Look at each stepor practice as part of a larger, holistic approachto working toward the health and safety of eachpatient by cultivating connections. Encouragecontact between the outpatient provider and thepatient prior to discharge. Find ways to buildconnections among the patient, family, and thenatural supports. Make use of peer specialists andothers with lived experience to support both thepatient and the family during the care transitionand throughout recovery. Build bridges. Take concrete steps to build a lastingstructure for effective and safe care transitions. Establish, follow, and evaluate protocols totriage appointments and arrange for rapidreferrals of patients with a history of suiciderisk. Revise protocols as needed to improve thecare transition process. Write formal agreements between inpatient andoutpatient provider organizations to elucidatetheir roles, responsibilities, and commitmentsto rapid referral and triaged appointments.Ensure that both organizations’ needs are met. Develop innovative strategies for narrowing thegap in care transitions. Maintain good communication through regularmeetings between organizations to develop thepartnership in patient care.Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care2
National Action Alliance for Suicide PreventionThe interval between the inpatient and outpatientsettings, no matter how brief, is a critical period forpreventing suicides. By working together, takingconcrete actions, and planning ahead, organizations canhelp ensure patient safety during the transition of care.Recommendations for Inpatient ProvidersThe following recommendations are appropriatefor inpatient psychiatric settings, such as hospitals,residential treatment centers, crisis stabilization units,behavioral health acute care units, or crisis respitecenters. See the Resources section for specific tools tosupport these processes.Prior to Discharge1. Develop relationships, protocols, and procedures forsafe and rapid referrals.As noted in the introduction, the first week afterdischarge from inpatient treatment carries extraordinaryrisk for suicide, with suicide deaths occurring during thisweek at a rate 300 times higher than the global suiciderate (Chung et al., 2019). Therefore, it is crucial thatpatients receive an outpatient appointment as soon aspossible after discharge from inpatient care and receiveongoing support until they attend that appointment. Forreferrals to be performed quickly and safely, inpatientfacilities must already have relationships, policies, andprotocols in place that will facilitate the referral processand support rapid outpatient appointment scheduling.Begin discharge planning upon admission.Discharge planning begins within 24 hoursafter admission and sets a clear expectation thathospitalization is a brief period of treatment, and thatpost-discharge care is needed (Agency for HealthcareResearch and Quality, 2019). The initial discharge goalsmay be very brief and may grow or develop during thecourse of treatment, building upon the initial needs,desires, and resources of the patient. Include the family» INPATIENT PROVIDERSand natural supports in building the after-hospitalizationdischarge plan. Their involvement gives the treatmentteam critical insights and perspectives and also preparesthe family and natural supports for discharge (Agencyfor Healthcare Research and Quality, 2019).Develop collaborative protocols. To ensurerapid referrals to outpatient counseling for patientswith a history of identified suicide risk, workcollaboratively with outpatient provider leadershipto expedite initial counseling appointments. Build ateam approach for a swift and smooth transition frominpatient to outpatient care.Negotiate a memorandum of understanding(MOU) or memorandum of agreement (MOA).Partner with outpatient provider organizations, towhich your organization often refers patients, andwrite a formal agreement that details care coordinationexpectations. The agreements include expedited medicalrecords sharing (e.g., transition plans, medicationslist, treatment plans, crisis/safety plans); tracking ofadmissions and discharges; coordination of specificservices for patients with a history of suicide; activefollow-up after discharge; and no-show follow-upprotocols (SAMHSA, 2019). These types of agreementsare becoming commonplace for ensuring carecoordination between health care organizations. Forexample, Certified Community Behavioral Health Clinicsare required to have partnerships or formal agreementswith inpatient psychiatric facilities and other local healthcare provider agencies (SAMHSA, 2016). Partnershipsand good communication are key to developing asmooth, seamless transfer of care with minimaldelays and barriers. For examples, please see theResources section.Electronically deliver copies of essential records.Help the outpatient provider build on the care that yourorganization provided by ensuring it receives copies ofessential records before the patient’s first visit. Examplesinclude current course of illness and treatment,Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care3
National Action Alliance for Suicide Preventiontransition/discharge plans, treatment plans, medicationslist, crisis/safety plan, releases of information, andemergency contacts list. Send the records at the time ofdischarge and forward the discharge summary as soon aspossible, preferably within 24 hours of discharge (Agencyfor Healthcare Research and Quality, 2019; Centers forMedicare and Medicaid Services, 2019).2. Involve family members and other natural supports.Encourage family participation. Family membersand other natural supports offer perspectives on thepatient’s struggles and are sources of support and caring,within the hospital setting and upon discharge. Familyand natural supports can include relatives, spouses,partners, and friends whom patients have identified asimportant to them (National Action Alliance for SuicidePrevention: Suicide Attempt Survivors Task Force, 2014).Involving the family and natural supports in the patient’scare decreases stigma, increases the friends’ and relatives’understanding of both suicide risk and any co-occurringmental health or substance misuse problems, underscoresthe need for ongoing care after hospitalization, andincreases the likelihood of the patient engaging inoutpatient care (Haselden et al., 2019).People in the support network may need some supportas well. Providing education and support to thefamily members and natural supports (e.g., throughpeer specialists, peer support groups, training, andlinkages to other sources of support) can increasethe efficacy of the natural support network for thepatient outside the hospital (Agency for Healthcare“ Involving the familyand natural supportsin the patient’s caredecreases stigma.”» INPATIENT PROVIDERSResearch and Quality, 2019). Create protocols and trainstaff on how to increase participation of family andnatural supports. Ensure training is then put into practice.Include peer specialists. Trained peer specialists havea personal experience with mental health care and arethemselves in recovery. Peer specialists can positivelyconnect with the patient from a personal perspective toprovide social and emotional support, to answer questionsabout life after hospitalization, to offer hope for recovery,and to help problem-solve practical problems, such astransportation, applying for health insurance coverage,accessing veterans’ benefits, obtaining medication refills,accessing local sources of support, finding stable housing,and many other questions.Example: Saint Elizabeth’s Hospital in Washington, D.C.makes use of peers to facilitate the transition from thehospital to community, especially for patients who havehad longer stays. The hospital’s peer support servicesassist with taking the patient to meet an outpatientprovider, prior to discharge, for a transition meeting.In addition, a peer meets individually with the patientafter discharge to review discharge plans, safety plans,and services. Patients reported the peers’ assistance andsupport as useful and beneficial as they transitionedback to the community, given the peers’ own experienceand understanding of the community and services. (M.Gaswirth, personal communication, October 8, 2019).Engage the school and community supports. Forchildren or teens preparing for discharge, reach out totheir school counselor to discuss supports and safetyneeds at school. With parental and student consent, sharethe safety plan with the school counselor and discuss waysthe school staff (counselor, teachers, coaches) can supportthe student after hospitalization. Connect the schoolcounselor with the outpatient behavioral health providerso both can support the student, within their appropriateroles.Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care4
National Action Alliance for Suicide PreventionExample: New Hampshire Hospital is dedicatedto ensuring youth are connected to support in theircommunity after discharge. The aftercare liaison worksclosely with the individual’s support network—such asfamily, friends, school staff, coaches, and therapists—todevelop an individualized plan to keep the patient safein a crisis and connected to community resources. Theliaison also provides the patient’s family or caregiverswith sources of educational materials and social support,such as NAMI NH programs. Working closely with thestate’s Regional Public Health Networks, the liaisonalso connects patients with local resources, such associal activities and classes that patients feel would behelpful after leaving the hospital. To learn more, visitSPRC Prevention in Practice-Care Transitions.3. Collaboratively develop a safety plan as part ofpre-discharge planning.Work collaboratively with the patient and his orher family members and natural supports to developa patient safety plan/crisis response plan (CARFInternational, 2019; Stanley & Brown, 2012). The safetyplan (Stanley & Brown, 2012) or crisis response plan(Bryan et al., 2017) is a written strategy for coping withsuicidal thoughts. This plan includes coping strategiesthat patients can use on their own; coping strategies thatinclude family members, friends, or other supports; andresources such as crisis lines. Including family membersand natural supports in developing the safety/crisis planincreases the safety at home, helps them understandthe need for home safety practices, details helpfulcoping strategies, and explains the need for ongoingcare with an outpatient behavioral health provider. Besure to discuss and address any lethal means (items/methods) in the homes that may need to be secured orhave reduced access. This includes firearms, certaintypes and quantities of medication, poisons, or othermethods the patient has contemplated or identified.Experience in Zero Suicide (an evidence-based approachfor transforming behavioral health care) suggests thatrigorous and confirmed steps to reduce and remove lethalmeans are one of the most potent tools for preventing» INPATIENT PROVIDERSsuicide (National Academies of Sciences, Engineering,and Medicine, 2018). Follow up with family members toconfirm they have improved safety at home by securingor reducing access to lethal means (items/methods) priorto discharge. Ensure that staff has the training to developsafety plans collaboratively and that expectations for thisare clear, and check to make sure the approach is beingimplemented. To learn more about safety planning andtalking with the patient and family members about lethalmeans, refer to the Resources section.“ Ensure that staff has thetraining to develop safetyplans collaboratively.”4. Connect with the outpatient provider.Schedule an outpatient appointment. With inputfrom the patient and family, secure an outpatientbehavioral health appointment at a date and time thatthe patient can attend, ideally within 24-72 hours ofdischarge and no later than seven days after discharge.Ensure that your staff follows your written policies andprocedures for facilitating outpatient counseling andproviding follow-up care (The Joint Commission, 2019).Talk with the patient, family members, and outpatientprovider to identify and resolve any potential barriersto attending the appointment (e.g., transportation,childcare, insurance, housin
Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care. This guide does the following: Discusses the challenges in care transitions and the need for better care practices and care coordination from inpatient to outpatient behavioral health care Presents feasible, evidence-based practicesFile Size: 509KB
Switch and Zoning Best Practices 28-30 2. IP SAN Best Practices 30-32 3. RAID Group Best Practices 32-34 4. HBA Tuning 34-38 5. Hot Sparing Best Practices 38-39 6. Optimizing Cache 39 7. Vault Drive Best Practices 40 8. Virtual Provisioning Best Practices 40-43 9. Drive
Project Work Plan: Transitions of Care Project Name .55 Stroke QI Transitions of Care Initiative Project Plan . stroke patient comes in contact. Include a Patient Perspective. It is recommended to find a way to obtain input from patients on changes that will impact their care. This may be identified through chart review and tracking trendsFile Size: 810KB
transition services related to health outcomes and a look at innovative initiatives and future directions in care transitions. t. ransitiOns Of. c. are and. c. are. c. OOrdinatiOn. Transitions of care involve efforts to ensure coordination and continuity while moving individuals from one setting of healthcare services to another (Naylor and .
child during transitions. In the next section, we provide ideas and strategies for planning, designing, and imple-menting transitions to support all children and to decrease the likelihood that challenging behavior will occur. Plan for success Designing a schedule that minimizes transitions
Spiral Curve Transitions Use spiral curve transitions for high-speed roadways. Drivers gradually turn into curves, with the path following a spiral curve. Roadway segments with spiral curve transitions have the potential for fewer crashes than segments without spiral curve transitions.
Animated transitions are used to convey state changes and engage viewers. We focus on animated transitions between statistical graphics, with the goal of accurately conveying changes, directing attention, and helping viewers stay oriented. 2.1 Animated Transitions Animation is a common method for conveying changes between visual-ization states.
actors. We find that actor roles in transitions are erratic, since their roles can change over the course of time, and that actors can belong to different categories. We conclude by providing recommendations for a comprehensive typology of actors in sustainability transitions. Keywords: transitions; actor typology; agency; sustainability 1 .
The Lockdown Haircut by Barbara Henderson 18 The Worst Birthday Ever by Maisie Chan 20 . And a world that’s still full of hope and love. Diana Hendry Looking Up LOCKdown Life. 2 3 A virus is a very small piece of organic matter, far smaller than bacteria. Viruses are not really living things. On their own they cannot grow or reproduce. When viruses infect a plant or animal, they get inside .
