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Puzzle Transition

Transition

Transition individuals through care with warm hand-offs and supportive contacts.

Transition

Transition with Care

In a Zero Suicide approach, careful attention is paid to the transition of individuals at risk of suicide between providers of care. Statistically, the transition period with the highest risk is between inpatient and outpatient care, however, each transition is a vulnerable time and requires careful planning to make sure individuals receive the care they need.

Inpatient to Outpatient Care

The period of time after an individual is discharged from inpatient for psychiatric and connected to outpatient care is a vulnerable time for people who are at risk for suicide. There is a 300% increased risk for suicide in the week after discharge from a psychiatric inpatient stay and a 200% increased risk for suicide in the 30 days after discharge.1 It did not matter what the diagnosis was. Even if someone was admitted for psychosis, their risk for suicide increased after discharge.1

The transition from the emergency department (ED) to behavioral health care is another critical transition. Individuals who go to the ED for suicidal thoughts or behaviors need to be carefully assessed and transitioned to the appropriate level of behavioral health care based on their risk level and needs. However, there are unique barriers in an ED which depend a great deal on available resources (e.g., staffing, transportation, community behavioral health providers, and other referral resources). However, it is imperative that providers carefully and completely bridge the transition from inpatient psychiatric care or the ED to outpatient behavioral health care and we discuss strategies in the other tabs set out above.

Here are some additional resources for inpatient to outpatient and ED to outpatient transitions:

Other Transitions

There are other important transitions too. For example, the period between a primary care visit and an appointment at behavioral health outpatient services can also be risky. There aren’t statistics on successful or unsuccessful referrals from primary care to outpatient treatment, but we know that strong links between them need to be built for safe and certain transitions for individuals with suicidal thoughts and/or behaviors. We do know that close to 30% of people who die by suicide visited a healthcare provider in the week prior to their death.2

Some examples of other transitions to prepare for:

  • When the individual is referred to a provider or service within or outside of the organization (i.e., therapist refers to psychiatric provider, current therapist leaves and the individual is transferred to a different therapist, referral for parenting or peer support, from substance use treatment to mental health treatment, referral to vocational organization, etc.)
  • When an individual transitions to another organization or provider in the community (i.e., clinic to clinic, outpatient to partial hospitalization program, respite to outpatient)
  • When an individual ends services, either independently or in agreement with the care provider
  • Following an individual’s contact with crisis services when a referral for additional care was made

Creating successful bridges in care can be a difficult and confusing process. It is essential that health and behavioral health care systems develop clear protocols and procedures that carefully engage individuals at risk of suicide, so those individuals make and keep the appointments that support their care. Effective care transitions are the responsibility of the provider, not the individual or their family members.

In a Zero Suicide approach:
  • Organizational policies provide clear guidance for successful care transitions and specify the contacts and supports needed throughout the process to manage the transitions.
  • Staff are provided training (initial and ongoing) appropriate for their role, on the importance of transitions and the organizational procedures to support transitioning individuals.
  • Care transition activities (e.g., phone calls to the individual or collaborating providers, postcards sent, and responses) are recorded in the organization’s health record.
  • Data are collected to identify gaps in care or training to continuously improve the processes and procedures regarding transitions of care.
  • A Just Culture spirit is maintained, particularly if there is an adverse event, and a systems-improvement focus is kept instead of a culture that faults individual service providers.
  • Leaders facilitate MOUs or other collaborative relationships between their organization and other organizations to improve the processes of interorganizational transitions.
  • Caring contacts are used with appropriate transitions (e.g., inpatient to outpatient, clinic to clinic).
Consider the following research findings:
  • A study that looked at data across 33 states found that if a young person was seen by a mental health provider within seven days after discharge from a psychiatric inpatient stay their suicide risk was reduced.3
  • Delays in follow-up care were related to the following characteristics: medical comorbidities, Black race, older age, shorter hospital stay, lack of previous mental health care, and managed care.3
  • Brief interventions such as safety planning, caring contacts, and care coordination reduced subsequent suicide attempts for individuals who presented with suicidal thoughts or behaviors in an ED or other medical environment.4
  • Strategies such as the use of technology, multidisciplinary team approaches, and co-locating medical and behavioral health providers can be helpful to bridge care, particularly for rural populations.5

At the tabs above, you’ll find information about specific transition strategies and the role of crisis center services in ensuring safe care transitions. For more information about the evidence supporting care transitions, please see the Evidence Base section of this website.

  • 1a1bChung, D., Hadzi-Pavlovic, D., Wang, M., Swaraj, S., Olfson, M., & Large, M. (2019). Meta-analysis of suicide rates in the first week and the first month after psychiatric hospitalisation. BMJ Open, 9(3), e023883. https://doi.org/10.1136/bmjopen-2018-023883
  • 2Ahmedani, B. K., Westphal, J., Autio, K., Elsiss, F., Peterson, E. L., Beck, A., Waitzfelder, B. E., Rossom, R. C., Owen-Smith, A. A., Lynch, F., Lu, C. Y., Frank, C., Prabhakar, D., Braciszewski, J. M., Miller-Matero, L. R., Yeh, H.-H., Hu, Y., Doshi, R., Waring, S. C., & Simon, G. E. (2019). Variation in Patterns of Health Care Before Suicide: A Population Case-Control Study. Preventive Medicine, 127, 105796. https://doi.org/10.1016/j.ypmed.2019.105796
  • 3a3bFontanella, C. A., Warner, L. A., Steelesmith, D. L., Brock, G., Bridge, J. A., & Campo, J. V. (2020). Association of timely outpatient mental health services for youths after psychiatric hospitalization with risk of death by suicide. JAMA network open, 3(8), e2012887-e2012887
  • 4Doupnik, S. K., Rudd, B., Schmutte, T., Worsley, D., Bowden, C. F., McCarthy, E., ... & Marcus, S. C. (2020). Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: a systematic review and meta-analysis. JAMA psychiatry, 77(10), 1021-1030.
  • 5LeCloux, M. A., Weimer, M., Culp, S. L., Bjorkgren, K., Service, S., & Campo, J. V. (2020). The Feasibility and Impact of a Suicide Risk Screening Program in Rural Adult Primary Care: A Pilot Test of the Ask Suicide-Screening Questions Toolkit. Psychosomatics, 61(6), 698–706. https://doi.org/10.1016/j.psym.2020.05.002