Purpose of Post-Discharge / Transition of Care Visits
To ensure continuity after discharge, reconcile medications, review discharge summary, assess current risk, and coordinate ongoing care.
Post-discharge risks (elevated suicide risk, medication errors).
Suicide risk is 300x higher in the first week and 200x higher in the first month after psychiatric discharge. The Action Alliance
- We are not a transitional program. We are ongoing outpatient psychiatry.
- Post-discharge appointments should:
- Confirm stability for outpatient level of care
- Reconcile meds
- Screen for relapse/suicidality
- Set clear boundaries for when patient needs to return to higher-acuity services
- Post-discharge appointments should:
Key Definitions
Post-Discharge
- Purpose: Focuses on follow-up care after a patient has been discharged from a hospital, skilled nursing facility, or other inpatient setting. The goal is to ensure the patient is recovering well, adhering to discharge instructions, and avoiding complications or readmissions.
- Scope:
- Review of discharge instructions.
- Medication reconciliation (ensuring medications prescribed post-discharge are correct and being taken properly).
- Addressing any immediate concerns or symptoms related to the recent hospitalization.
- Monitoring for signs of complications or worsening conditions.
- Timing: Typically occurs within a few days to a week after discharge, depending on the patient’s condition and risk factors.
- Focus: Short-term, specific to the recent hospitalization.
Transition of Care (TOC)
- Purpose: Broader in scope, focusing on the safe and effective transition of a patient from one care setting (e.g., hospital) to another (e.g., home, primary care, or skilled nursing). The goal is to coordinate care across providers and settings to prevent gaps in care and reduce readmissions.
- Scope:
- Comprehensive review of the patient’s medical history, current condition, and care plan.
- Coordination with other healthcare providers (e.g., specialists, home health services).
- Addressing social determinants of health (e.g., transportation, access to medications, caregiver support).
- Long-term care planning and follow-up.
- Timing: Must occur within 7 or 14 days of discharge (depending on the complexity of the patient’s condition) to meet billing requirements for TOC services.
- Focus: Holistic, addressing both short-term and long-term needs to ensure continuity of care.
New Appointment Types for Discharge and Transition of Care
Post-Discharge – 30 min
Transition of Care – 40 min
Deciding between Post-Discharge and Transition of Care
Decision TreeDischarge Facility Types: TOC Eligible vs. Non-Eligible
| Facility Type | TOC | Post-Discharge | Description |
|---|---|---|---|
| Inpatient Psychiatric Hospitals | Yes | Yes | Hospitals specializing in mental health stabilization and treatment. |
| Intensive Outpatient Programs (IOP) | Yes | Yes | Structured outpatient programs for mental health or substance use treatment. |
| Partial Hospitalization Programs (PHP) | Yes | Yes | Day programs offering intensive therapy for mental health or substance use. |
| Primary Care Clinics | Yes | No | Clinics managing follow-up care and chronic conditions post-discharge. |
| Rehabilitation Centers | Yes | Yes | Centers focused on physical, occupational, or substance use rehabilitation. |
| Residential Treatment Centers (RTC) | No | Yes | Live-in facilities for mental health, behavioral, or substance use treatment. |
| Specialty Clinics | Yes | No | Clinics focusing on specific conditions (e.g., cardiology, oncology). |
Medicare and most payers define TCM eligibility around inpatient-type or skilled settings (hospital inpatient, observation, skilled nursing facility, partial hospitalization). Residential treatment centers, even though they feel like inpatient, are typically classified as non-medical or custodial behavioral health facilities, not acute/skilled medical facilities.