Improving community care for patients discharged from hospital through zone-wide implementation of a seamless care transition policy

Abstract

Abstract Background Several studies within the psychiatry literature have illustrated the importance of discharge planning and execution, as well as accessibility of outpatient follow-up post-discharge. We report the results of implementing a new seamless care transition policy to expedite post-discharge follow-up in the community Addiction and Mental Health (AMH) program in the Edmonton Zone, Alberta, Canada. The policy involved a distribution mechanism for assessment by a mental health therapist (MHT) within 7\u2009days of discharge as well as a dedicated roster of community psychiatrists to accept newly discharged patients. Objective Our aim was to assess the feasibility of this novel policy and to assess its effect on our outcome measures of wait time to first outpatient MHT assessment and re-admission rate to hospital. Methods Our study involved a retrospective clinical audit with total sampling design and a comparison of data 1 year before (2015/2016 fiscal year) and 1 year after (2017/2018 fiscal year) the implementation of the seamless care policy within the Edmonton Zone. Extracted data were analyzed with simple descriptive statistics and presented as percentages, mean and median. Results Overall, with the enactment of this policy, follow-up volumes ultimately increased, while wait times for initial assessment decreased on average for patients discharged from the hospital. In the 2015/2016 fiscal year, MHT completed 128 assessments of post-discharge patients who were new to the community AMH program compared to 298 completed new assessments for the 2017/2018 fiscal year. The corresponding wait times for the new MHT assessments were 12.7\u2009days (median of 12\u2009days) and 7.8\u2009days (median of 6\u2009days), respectively. Similarly, psychiatrists completed only 59 assessments of post-discharge patients who were new to AMH compared to 133 new psychiatric assessments for the 2017/2018 fiscal year. The corresponding wait times for the new psychiatric assessments were 15.3\u2009days (median of 14\u2009days) and 8.8\u2009days (median of 7\u2009days), respectively. We correspondingly found a slight decline in readmission rates after the implementation of our model in the subsequent fiscal year. Conclusion We envision that this policy will set a precedent with regard to streamlining post-discharge follow-up care for admitted inpatients, ultimately improving mental health outcomes for patients.