Transition

Care transitions are high-risk times for patients. Caregivers, first responders, community agencies and clinicians must bridge patient transitions from inpatient, ED, or primary care to outpatient behavioural health care. It is important to address suicide risk at every visit within an organisation, from one clinician to another or between primary care and secondary health staff within integrated care settings.

The burden lies on the provider, rather than on the patient and family members, to develop systems to ensure that patients make and keep appointments.

In a Zero Suicide approach:

  • Organisational policies provide guidance for successful care transitions and specify the contacts and support needed throughout the process to manage any care transition.
  • Follow-up and supportive contacts for individuals on a suicide care management plan also called a pathway to care, are tracked and managed formally.

Key Steps in Developing Policies for Safe Care Transitions

  • Develop internal written policies, procedures and contracts or memoranda of understanding with outside organisations, including local crisis centres for safe care transitions:
    • When the patient is referred to a provider or service both within or outside of your organisation.
    • When the patient transitions to another organisation or provider in the community.
    • When the patient terminates services, either independently or in agreement with the care provider.
    • When the patient repeatedly misses appointments.
    • Following a patient’s contact with crisis services.
    • At discharge from an ED or a psychiatric hospital.
  • Train staff on policies and procedures for safe care transitions.
  • Ensure that patients receive education about the model of care and the rationale for treatment as they move from one clinician to another, or from one agency/setting to another.
  • Monitor to ensure that care transitions are documented and flagged for action in an appropriate health record.

In the sections below, you’ll find information about specific transition strategies and the role of crisis centre services in ensuring safe care transitions.

Emerging Standards

The emerging standard in suicide care requires innovative approaches to creating smooth and uninterrupted care transitions from one setting to another with support and contact provided throughout by the behavioural health provider, physician, or other designated staff from the organisation.

Specifically, the referring clinician or other staff members should:

  • Revise the patient’s safety plan before discharge or referral.
  • Ensure the patient has spoken by phone with the new provider.
  • Send patient records several days in advance of the appointment to the new treatment provider.
  • Call the new provider to go over patient information before the first appointment.
  • Contact the patient within 24–48 hours after they have transitioned to the next care provider and document the contact.

The health record plays a key role in assuring the following:

  • Patient appointments inside or outside an organisation are recorded.
  • No-shows are flagged and actions are taken to locate the person, ensure their safety, and reschedule the appointment or link them to a higher level of care if necessary.
  • Patient information, especially information about suicide risk and previous care is transmitted to the receiving provider.

Of course, organisations should obtain patient consent to share patient health information.

Safe Care Transitions

To ensure continuity of care for suicide risk, it’s important to remove barriers to scheduling a patient’s follow-up appointments. Organisations should establish agreements or subcontracts between acute care settings and outpatient providers to ensure recently discharged high-risk patients have appointments within 24 hours.

Warm Hand-Off

The goal of a warm hand-off is to increase the likelihood that a patient will follow up on a referral to one provider from another. Rather than simply providing the name and phone number of a provider, as happens frequently, a warm hand-off connects the patient with the new provider before the first appointment.

An example of a warm hand-off would be when an emergency department, primary care, or inpatient staff member facilitates a phone call between a patient and an outpatient provider before the patient’s first appointment with that provider. The contact can also be made in person or with an interim contact, such as a crisis centre worker or peer specialist, who will follow up to encourage the patient to keep the appointment.

Rapid Referral 

Rapid follow-up and referral involves taking steps during an emergency department visit or before discharge from inpatient care to facilitate immediate access to an outpatient treatment appointment for the patient, preferably within 24–48 hours after discharge. To facilitate rapid referral, it may be helpful to establish agreements with outpatient providers to accept rapid follow-up referrals.

Organisation policies should provide for:

  • Scheduling the first outpatient appointment before the patient is discharged if the outpatient provider is reachable.
  • Leaving a message with the outpatient provider to request priority scheduling for the patient upon discharge, if the provider is not reachable.

Caring Contacts

Caring contacts are brief communications with patients during care transitions such as discharge from treatment or when patients miss appointments or drop out of treatment. These contacts, through which care providers continue to show support for a patient, can promote a patient’s feeling of connection to treatment and increase his or her participation in collaborative treatment. Caring contacts may be especially helpful for patients who have barriers to outpatient care or are unwilling to access this care.

Examples of caring contacts include:

  • Postcards, letters, e-mail messages, and text messages. Automated systems can be used to send any of these, as these allow for two-way communication between client and provider, which can help maintain support for the client between appointments.
  • Phone calls made by clinical or non-clinical staff, including peers who have experienced a suicide attempt. Individuals making phone contacts must be trained.
  • Home visits.

Organisations should consider establishing an agreement with a local crisis centre that can provide these caring contacts with recently discharged patients. The Role of Crisis Centres section, below, includes information about the services that crisis centres offer in support of patients at risk of suicide.

Other Bridging Strategies

The following are more examples of transition strategies:

  • Brief patient education that helps the patient understand his or her condition and what treatment options exist to facilitate patient and family follow-through.
  • Assistance with understanding and navigating the system of potential supports, preferably from a peer. Sometimes called peer or community bridging.
  • Onsite counselling by staff from a community-based organisation who can then see the patient for follow up care after discharge.
  • Providing the patient with a copy of his or her safety plan or updating a safety plan to make sure it is relevant for the current level of care.

Crisis Services

In the field of suicide prevention, the term crisis services has often meant a hotline or helpline model of care, such as counsellors staffing phone lines or, increasingly, text or chat lines assisting often anonymous callers with a suicidal or behavioural health crisis. In some cases, people with ongoing suicidal thoughts or chronic mental illness may use this kind of crisis support to cope with emerging thoughts of suicide or distress. Crisis centres provide this confidential service 24/7.

Crisis services can also include:

  • Mobile crisis teams.
  • Walk-in crisis clinics.
  • Hospital based psychiatric emergency services.
  • Peer based crisis services.
  • Care coordination services, which have been shown to positively impact outcomes, increase attendance in outpatient appointments, and lower readmission rates for high utilising patients.
  • Other programs designed to provide assessment, crisis stabilisation, and referral to an appropriate level of ongoing care.

Crisis centres can also serve as a connection with the patient between outpatient visits. These services can be particularly helpful for patients with barriers to accessing outpatient mental health services.

Incorporating Crisis Services

Research suggests that providing a full range of crisis services can reduce involuntary hospitalisations and suicides when paired with mental health follow up care. Communities ideally should offer a full continuum of services designed to provide the right care at the right time and support an individual’s ability to cope with suicidal thoughts or feelings.

To incorporate the use of crisis services, health and behavioural health organisations should:

  • Make formal agreements or subcontract with crisis centres to provide follow-up services for their patients.
  • Provide written information with the crisis centre phone number to every patient with suicide risk as part of a formal safety plan.
  • Provide every patient with crisis centre information upon discharge from treatment.
  • Explain the purpose, utility, and services offered by the crisis centre to every patient and his or her family, both at the start of treatment as well as at discharge.
  • Obtain patient consent prior to discharge from inpatient or emergency department care for a crisis centre to provide follow-up support in the form of phone calls.
 

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