The Effectiveness of Discharge Planning for Psychiatric Inpatients With Varying Levels of Preadmission Engagement in Care

The final study sample included 18,793 psychiatric inpatient admissions involving 18,793 unique patients, all of whom were discharged to the community. Grouping the patients on the basis of level of engagement with psychiatric services during the 6 months before inpatient admission identified 7,927 (42.2%) patients in the high-engagement group, 1,968 (10.5%) in the partial-engagement group, 3,648 (19.4%) in the low-engagement group, and 5,250 (27.9%) in the no-engagement group. Figure 1 shows 7- and 30-day rates of attending care after discharge for the high-, partial-, low-, and no-engagement groups. Follow-up rates progressively increased by level of engagement in care prior to admission.

Table 1 describes patient characteristics of the total sample and the four engagement groups. Patterns were consistent among the groups and were more pronounced in the groups with lower levels of engagement in care before admission. Compared with patients who were highly engaged in care, those with no psychiatric visits in the 6 months before admission were more likely to be Black (compared with White), older (relative to the 4–12-years-old group), and to have shorter (0–4 days) LOS. Patients not engaged in care prior to psychiatric admission were also more likely to be homeless, have a co-occurring substance use disorder, and have a primary mood disorder (compared with a psychotic disorder) diagnosis and were less likely to have co-occurring medical conditions. Table 2 lists hospital- and system-level characteristics for the total sample; none of these variables were consistently associated with level of engagement in psychiatric care before admission.

Among those who were highly engaged in care prior to admission, 15.1% (N=1,151) did not have an appointment scheduled. This proportion progressively increased among the other groups; among those with partial, low, or no engagement in care prior to admission, 18.0% (N=339), 21.6% (N=751), and 28.0% (N=1,374), respectively, did not have an appointment scheduled before discharge. (Ns and percentages were based on data with missing information about whether some patients attended an appointment.) Figures 2 and 3 present the proportions of patients attending outpatient appointments within 7 and 30 days after discharge, respectively, adjusted for the patient, hospital, and service system characteristics described in Table 1. For each of the four patient groups defined on the basis of level of engagement in care prior to admission, scheduling an outpatient appointment as part of the patient’s discharge plan was significantly associated with attending an initial outpatient psychiatric appointment within both 7 and 30 days after discharge. In the group of patients who had not received any outpatient care in the 6 months before admission, those for whom the inpatient team scheduled an outpatient appointment as part of their discharge plan were approximately three times more likely than those who did not receive an outpatient appointment to follow up with care within 7 days and more than twice as likely to follow up within 30 days.

This study examined associations between scheduling appointments during discharge planning and follow-up outpatient treatment among patients with varying levels of engagement in care prior to hospital admission. We report three key findings. First, only 42.2% of patients were highly engaged in outpatient psychiatric care in the 6 months before a psychiatric inpatient admission. Second, patients who were less engaged in care before admission were less likely to have an appointment scheduled with an aftercare provider. Third, having an appointment scheduled as part of the discharge plan was associated with successful care transition regardless of the patient’s level of engagement in care prior to the admission.

Our hypotheses that the association between appointment scheduling and attendance at follow-up appointments would be weaker or nonexistent for patients who were partially or not engaged in care before the admission were not supported. Rather, we found that scheduling an outpatient appointment before discharge remained strongly associated with postdischarge follow-up regardless of patients’ level of engagement in psychiatric care prior to admission. Even among patients who received no psychiatric services in the 6 months prior to admission, whose overall follow-up rates were the lowest, those for whom the inpatient psychiatric team scheduled an outpatient appointment as part of the discharge plan were approximately three times more likely than those who had no scheduled follow-up appointment to attend a follow-up psychiatric visit within 7 days and more than twice as likely to attend a visit within 30 days.

Lack of engagement in care prior to inpatient psychiatric admission strongly predicts failed care transitions (1, 2). We defined four levels of engagement in outpatient psychiatric care based on intensity of services received over a 6-month period before hospital admission. The finding that only a minority (42.2%) of patients met our definition of being highly engaged in care before their hospital admission confirms previous studies indicating that poor access or adherence to community-based psychiatric care is a common antecedent to acute inpatient psychiatric care (2). Our approach to measuring engagement in outpatient psychiatric care may inform future quality improvement efforts.

In our sample, patient characteristics were more strongly associated with level of engagement in care prior to admission than were hospital or service system characteristics. Two of the significant patient characteristics, being homeless and having a co-occurring substance use disorder, are known predictors of poor treatment outcomes (1, 14). Patients who had a shorter inpatient LOS were also more likely to have been disengaged from outpatient psychiatric services before hospital admission. This group might include patients who were refusing treatment, were admitted on involuntary holds because of concerns about safety, or were discharged when the treating psychiatrist could no longer identify safety concerns. Other patient characteristics associated with poor engagement in care prior to admission, including older age, being Black, having a primary mood disorder, and not having significant comorbid medical conditions, are more difficult to explain. Of note is the finding regarding Black patients, who have been shown to have lower engagement rates in psychiatric care (40). Acute psychiatric care systems need to prioritize efforts to better understand and address the needs of Black individuals with psychiatric illness experiencing crises, including the potential impact of provider bias, patient distrust, and institutional racism on access to and retention in care.

Previously published analyses of adult patients discharged to the community after inpatient psychiatric care revealed that 77% had an outpatient appointment scheduled with a psychiatric provider as part of their discharge plan (29, 35). The current analysis indicated that inpatient treatment teams were less likely to schedule postdischarge appointments for patients who were not engaged in care before admission. This finding may reflect a lack of community providers with available appointment times. In the current and previous analyses (29), however, we did not find associations between outpatient provider density and scheduling appointments or follow-up attendance. This association may also be because these patients were more likely to refuse discharge planning, or it may reflect a bias on behalf of inpatient providers to offer less discharge planning to patients they believe to be less likely to follow up. Importantly, our findings suggest that inpatient teams should offer to schedule outpatient follow-up appointments for all patients discharged from inpatient psychiatric care regardless of their level of engagement in psychiatric care before hospital admission.

There are several possible explanations for the associations between scheduling an appointment and attending postdischarge visits. For patients who were previously engaged in outpatient care, scheduling an appointment may serve as a reinforcement of the need for timely follow-up and may limit the potential for confusion and discontinuity after discharge. For patients with low or no engagement in outpatient care prior to admission, scheduling an aftercare appointment may create an opportunity for continued care that some patients take advantage of after discharge, despite their prior difficulties accessing treatment. Our data indicate that many such patients take advantage of this opportunity. This finding has important implications; hospital providers who do not offer discharge planning to patients who are leaving against medical advice or otherwise refusing to collaborate on discharge planning should consider revising their policies to ensure that all patients receive a follow-up appointment regardless of the circumstances of their discharge.

Additional factors may contribute to our finding that scheduling appointments was associated with successful care transitions for patients with low or no previous engagement in care. Some patients who previously had not engaged in care may have been affected by their current episode or circumstances in such a way that they became more motivated to seek outpatient care and collaborated with the inpatient treatment team on a discharge plan that included a scheduled appointment with an outpatient provider. Relatedly, for some patients, the inpatient treatment team may have accurately perceived other indicators that the patient was more likely to follow up and preferentially scheduled appointments for those individuals. We do not have data to address either of these possibilities.

Potential limitations to this study included the possibility that unmeasured variables, such as transportation constraints, may have affected attendance at outpatient appointments. We also relied on multiple MBHOs independently reporting provider discharge planning activities, creating significant potential for measurement error. Findings from a Medicaid population may not generalize to commercial or Medicare populations, and the New York State Medicaid population likely differs from other state Medicaid populations given variations in eligibility and enrollment practices across states. Additionally, the results are based on patients with 1 year of near-continuous Medicaid enrollment and may not generalize to those with shorter enrollment.

One may also question whether data regarding discharge planning practices from 2012–2013 reflect contemporary practice, given the impact of recent health care reforms related to the Affordable Care Act. We believe the findings reported herein remain highly relevant because of the paucity of quality measures for behavioral health and because 7- and 30-day follow-up after hospitalization for mental illness, which should be sensitive to discharge planning practices, remain among the most commonly used measures in quality and performance measurement programs. Published reports indicate that hospital ratings on these measures did not change appreciably from 2005 to 2015 despite implementation of multiple state and federal quality and value-based initiatives (41, 42). Currently, publicly reported national average 7- and 30-day follow-up rates among Medicare recipients available online at the Centers for Medicare and Medicaid Services Hospital Compare website (https://www.medicare.gov/care-compare/#search) are 27.7% and 49.4%, respectively. These continued low rates further underscore the need for heightened focus on discharge planning practices and care transitions in this population, making our findings highly relevant.

Discharge planning activities, such as scheduling follow-up appointments, increase the likelihood of patients successfully transitioning to outpatient care, regardless of their level of engagement in care prior to psychiatric inpatient admission. Future research should examine mechanisms underlying successful discharge planning and care transitions, including potentially relevant issues such as the role of familiarity of the community-based provider and whether additional discharge planning practices (e.g., forwarding care summaries or follow-up communications) further improve engagement in psychiatric care after hospital discharge.