Bridging the gap: Virtual psychiatric transition of care from acute to outpatient settings

Abstract

BACKGROUND

Timely and successful transition to outpatient care following inpatient behavioral health treatment or emergency department discharge is critical to reducing suicide risk and preventing mental health deterioration. To address this, the virtual psychiatric transition of care (VPTC) program was developed by the Department of Psychiatry at Atrium Health.

AIM

To provide virtual, multidisciplinary support to patient’s post-discharge, facilitating access to appropriate outpatient services.

METHODS

Patients enrolled between August 2021 and August 2023 were included in a retrospective evaluation of the VPTC program’s implementation. The program provided support across six inpatient Behavioral Health facilities, a Department of Behavioral Health Emergency with an Observation Unit, and a Consult Liaison Unit. All participating sites operate within a single, large, fully integrated healthcare system located in the southeastern United States. Outcomes include compliance with follow-up care, acute care utilization, and patient well-being.

RESULTS

Over 1500 patients were supported, with 205 follow-up visits completed through VPTC, including 84 hospital follow-ups. The hospital follow-up rate of 63% exceeded both the national average (40%-50%) and comparable internal benchmarks (37%). The program also surpassed targets for reducing symptoms of depression and anxiety, while patients reported high satisfaction, citing convenience, privacy, and ease of access.

CONCLUSION

The VPTC program is feasible and has shown early positive effects in supporting continuity of care and reducing acute service use. A virtual program can address patient well-being and potentially drive reductions in avoidable utilization of high-cost services. This program is a model for promoting recovery and supporting patients in navigating their transition to community-based behavioral health care.

Key Words: Virtual psychiatric transition of care; Virtual care; Behavioral health; Telepsychiatry; Post-discharge support; Care coordination, Mental health services

Core Tip: A virtual care program has the potential to strengthen postdischarge support for individuals living with mental illness by expanding access to timely care, reducing the risk of suicide, and decreasing dependence on high-cost acute services. Through structured follow-up and coordinated communication, the virtual psychiatric transition of care program helps patients successfully engage with outpatient providers, promoting sustained recovery, continuity of treatment, and long-term psychological well-being.

INTRODUCTION

The transition from inpatient psychiatric care to outpatient follow-up represents a critical period in the recovery process for individuals with mental health conditions. This period is characterized by heightened vulnerability, as patients navigate complex clinical, social, and systemic challenges that can disrupt recovery and continuity of care[1,2]. Ensuring continuity of care during this post-discharge phase is essential to minimize relapse risk, reduce rehospitalization, and promote long-term mental health stability[3]. Patients recently discharged from psychiatric hospitals or emergency department settings are an especially high-risk population. Nearly half (49%) report suicidal ideation at the time of discharge[4]. Evidence shows that the suicide risk is highest immediately after admission and right after discharge[5,6]. Many patients also experience significant emotional, physical, and psychological vulnerability following hospitalization, which can compromise their ability to engage with outpatient services[1].

Despite the recognized importance of timely follow-up, national data indicate that attendance at outpatient visits after psychiatric discharge remains suboptimal. A 2023 review by the National Committee for Quality Assurance reported that only 29% of Medicare patients, 38% of Medicaid patients, and 49% of privately insured patients attended their post-discharge mental health appointments[7]. Barriers contributing to these low rates include transportation difficulties, limited access to outpatient clinics, poor care coordination, social determinants of health, and the burden of persistent psychiatric symptoms[8,9]. To address these barriers, evidence increasingly supports the implementation of clinical bridging strategies. These are structured interventions that maintain therapeutic engagement and care continuity following inpatient discharge[10]. Virtual psychiatric care models, including telepsychiatry and remote case management, have emerged as effective tools to bridge this critical transition period[11].

The virtual psychiatric transition of care (VPTC) program developed within the healthcare system provides a comprehensive virtual support system designed to reduce suicide risk, prevent avoidable acute care utilization, and facilitate seamless connection to outpatient psychiatric services. The VPTC program incorporates multidisciplinary care coordination, psychiatric and pharmacologic consultations, and patient-centered flexibility through telehealth delivery. By leveraging virtual care modalities, the VPTC program addresses logistical barriers to in-person visits and enhances patient engagement during high-risk transitional periods.

At the time of its development in 2021, no other behavioral health program within the region, or more broadly within NC (United States), offered a comparable virtual bridge between inpatient discharge and outpatient psychiatric care. The program was developed to address system-wide patient experience goals, including improved care transitions, reduced psychiatric readmissions, shorter hospital stays, and enhanced patient satisfaction and symptom management. This program offers increased flexibility in scheduling and eliminating the need for patients to navigate logistical challenges associated with attending in-person appointments. Grounded in a growing body of evidence supporting telepsychiatry and remote monitoring, the VPTC program represents an innovative, scalable approach to improving continuity and outcomes for recently hospitalized psychiatric patients. The program implementation is outlined in this article.

MATERIALS AND METHODS

Enrolled patients from August 2021 through August 2023 were included in a retrospective assessment of the implementation of the VPTC program. The program supported patients across six inpatient Behavioral Health Facilities, one Department of Behavioral Health Emergency and Observation Unit, and one Consult Liaison Unit. Each of these facilities are part of one large fully integrated healthcare system in the southeast region of the United States. The foundational idea for the VPTC program came from the Atrium Health Hospital at home care model[12]. A behavioral health care team comprised of licensed clinicians (behavioral health professionals), health coaches, a consulting psychiatric pharmacist and psychiatric providers follow patients for approximately 45 days after their acute care encounter. Patients enrolled in the VPTC program receive the following components: (1) Introduction to the patient follow-up process; (2) Psychosocial assessment; (3) Virtual psychiatric hospital follow-up visits; (4) Tracking and treatment recommendations (e.g., residential movement, nutrition, sleep hygiene, stress management, pain management, perinatal/postpartum mood disorders, substance use disorder); (5) Tracking and treatment recommendations for behavioral health symptoms (e.g., depression, anxiety, suicidal ideation); (6) Placement into an appropriate case management program if needed; (7) Navigation to additional psychiatric or substance use services if needed; and (8) Motivational interviewing and brief therapeutic recommendations if needed.

Setting and sample/participants

Once discharge planning begins, doctors or discharge planners can make referrals to the program. Eligible patients included anyone discharged from any of the seven inpatient psychiatric units or psychiatric Department of Behavioral Health Emergency in the healthcare system. The patient population included patients 18 years of age or older at time of discharge, a resident of the state of NC (United States) and access to a phone. There were no exclusionary diagnoses of being eligible for the program. Once a referral to the program is made, VPTC staff attempts to make contact with the patient while they are still on the unit. This could be conducted via video or audio, depending on the available technology. If the staff cannot contact the patient prior to their discharge, the staff is to call the patient’s identified phone number within 24 hours of discharge to offer enrollment. During the enrollment call, the VPTC staff explains the program and what it entails. Once a patient gives consent to participate in the program, they would be scheduled to complete a brief intake assessment with a licensed clinician. Outreach services (health coach and safety checks) were all conducted telephonically. Medication management visits were all virtual and conducted by video (e.g., camera phone, tablet, computer). A series of foundational workflows were developed, including procedures for receiving referrals, conducting enrollment meetings with patients, initiating outreach, and enforcing safety protocols.

Standard of care before intervention

As part of the standard discharge process from a psychiatric facility, patients collaborate with their psychiatric care team to determine the most appropriate next level of care. Most patients transitioning back to the outpatient setting are discharged with a follow-up appointment scheduled at a community-based psychiatric clinic. This appointment is typically scheduled based on the first available appointment offered by the clinic. Ideally, this appointment would be within five to seven business days post-discharge but could exceed this timeframe based on availability or structure of the clinic. Some outpatient programs required patients to attend a therapy session prior to being scheduled with a psychiatrist. Upon discharge, each patient would be provided with a copy of their individualized safety and care plan, developed during their inpatient/observation stay. Patients also received a list of crisis hotline numbers and other relevant community-based resources.

VPTC program - description and implementation

The VPTC program was developed to enhance continuity of care and provide structured post-discharge support for individuals transitioning from inpatient Behavioral Health Units or Department of Psychiatric Emergency. This virtual program delivers weekly engagement calls for approximately 45 days following discharge. Participants were granted immediate access to an interdisciplinary team upon discharge. The team consisted of licensed practical nurses, health coaches, licensed clinicians, and psychiatrists. The licensed practical nurses verified medication information, triaged pharmacy issues, and facilitated coordination with the virtual program. Health coaches conducted weekly outreach calls to assist with treatment adherence, resource navigation, and appointment support. Clinicians performed initial psychosocial assessments, conducted safety evaluations, developed treatment plans, and responded to safety concerns throughout the program. Psychiatrists also provided medication management and clinical oversight for patients enrolled in the virtual program.

Weekly engagement sessions include a standardized safety assessment, review and revision of safety planning, referral and connection to community-based resources, medication education, and the development of individualized treatment goals and care plans. The VPTC team also facilitates navigation to outpatient behavioral health services, including psychiatric medication management, and provides ongoing support in addressing barriers to follow-up care. A collaborative, patient-centered approach is employed to promote adherence to outpatient treatment plans.

In addition to outreach services, the VPTC program provides virtual psychiatric medication management completed by a psychiatric provider. These appointments are not required, but they do allow a continuous bridge for patients as they wait to become established with a community provider. The program also offers hospital follow-up appointments within 7 business days post-discharge and provides bridge appointments until patients can establish ongoing care with their community-based behavioral health provider. The program specifically addresses barriers to timely and comprehensive outpatient follow-up care by supporting patients and their families as they navigate the healthcare system. The virtual structure allows for real-time updates to individualized treatment plans based on patients’ evolving needs in the community. Without this structured support, patients are often required to independently manage symptoms, navigate resources, and adhere to medication regimens, which may increase the risk of acute care utilization. The VPTC program was implemented through a phased rollout, beginning with a pilot site to identify potential operational challenges. Following successful testing for four months, the program was scaled to additional locations.

Post-discharge outreach workflow

The telephonic outreach phase began within two to three business days post-discharge. A licensed clinician completed an initial assessment to evaluate clinical needs and safety. If no acute safety concerns were identified, patients were scheduled for weekly outreach calls from health coaches. A safety plan was developed for patients who endorsed suicidal ideation during the assessment and received more frequent monitoring as clinically indicated. During weekly engagement calls, the care team facilitated the development and discussion of personalized treatment plans. This could include health goals, physical goals, or further exploring coping skills to manage their symptoms, and assist with connections to community resources. Appointment reminders and barrier assessments were also conducted to improve follow-up compliance.

Patients were screened at multiple intervals using standardized assessments. The Patient Health Questionnaire 9 (PHQ-9)[13] and Generalized Anxiety Disorder 7[14] were administered at intake, mid-program, and program completion; the Columbia-Suicide Severity Rating Scale (C-SSRS)[15] was administered during every outreach to monitor safety. Patients enrolled were considered to have successfully completed the program if they completed the 45-day outreach period or participated in a minimum of four outreach sessions and were connected to appropriate follow-up care (e.g., outpatient psychiatry, community-based therapist, intensive outpatient programs, or partial hospitalization programs).

Patients eligible for a virtual psychiatric medication consultation (defined as having access to video technology and unable to obtain a hospital follow-up appointment elsewhere within 5-7 days) would have their virtual visit within seven business days following discharge. The patient would have a video appointment with a psychiatric provider who would complete a review of their current and past medications, brief psychosocial assessment, and current symptoms. They would also review a patient’s discharge plan and determine if any further adjustments were needed to their medications. Patients were eligible for continued follow-up appointments until they were established with an outpatient psychiatric provider in the community.

Implementation support and materials

Marketing and engagement materials were developed to promote the program including brochures, frequently asked questions sheets, and discrete business cards containing VPTC contact information for patients upon discharge. Initial stakeholder meetings were conducted with facility leadership, unit staff, and community partners to establish alignment and shared objectives. These meetings were essential in securing the successful launch of this program through buy-in and support. A comprehensive onboarding process was developed for the inpatient unit staff, detailing training content, timelines, and follow-up procedures to ensure consistent implementation and understanding of program goals. The onboarding process for a new location took about two weeks. This led to the need for a phased rollout with enough time between new sites to manage questions and any issues with the referral pathway.

To streamline clinical operations, documentation templates were created and integrated into the electronic medical record system, enhancing efficiency and consistency in patient care documentation. Collaboration with the Information and Technology team facilitated the creation of data tracking mechanisms to monitor program outcomes. A dedicated phone system was also established to support communication needs across teams and patients.

Measures

Baseline assessments were completed at the start of enrollment and at the end of participation. The battery of assessments was chosen to show that services in the VPTC program could increase compliance with follow-up care, decrease acute care utilization, and improve patient well-being. Targets were developed by using national average data and data from other internal healthcare system transition programs. Acute care utilization was limited to any of the seven hospitals/Department of Emergency within the healthcare system that have a Behavioral Health Unit or are a Department of Behavioral Health Emergency.

Reduction in behavioral health utilization (inpatient or Department of Emergency) within 45 days of discharge (yes/no; target 13%). Reduction in admission to an inpatient psychiatric unit within 30 days of discharge (yes/no; target 6.5%). Decrease in reported suicidal ideation as measured by the C-SSRS (post-pre score; target 80%). Decrease in depressive symptoms as measured by the PHQ-9 (post-pre score; target 45%). Increased compliance with outpatient behavioral health follow-up appointment (yes/no; target 65%).

Statistical analysis

Data were extracted from the enterprise data warehouse and included both descriptive demographic characteristics (e.g., gender, race, ethnicity) and acute care encounter dates. Endorsement of suicidal ideation was defined as a yes to questions 2 or 6 utilizing the C-SSRS and recorded as yes/no. Total PHQ-9 score was captured from the PHQ-9 tool and recorded as a continuous variable. Surveys were pulled between enrollment date and graduation date from the program. The McNemar’s test was used to examine the shift in frequencies of the C-SSRS. The paired t-test was used to assess the means of the PHQ-9 total score at the start and end of the VPTC program. The 45-day utilization to a Behavioral Health Unit or Department of Behavioral Health Emergency was defined as an encounter resulting in an admission at a Behavioral Health Unit (inpatient or observation) or Department of Behavioral Health Emergency within the healthcare system within 45 days of their initial discharge. The 30-day inpatient psychiatric unit utilization was defined as an encounter resulting in an admission to an inpatient Behavioral Health Unit within 30 days of their initial discharge. The 30-day all cause non-elective utilization is similar to Medicare’s readmission measure[16] but includes observation admissions and the readmitting encounter can be at any facility within the healthcare system. Univariate analysis was utilized to examine frequencies of the measures. All analyses were performed using SAS software[17].

RESULTS

Patient characteristics are summarized in Table 1. A total of 1382 patients were enrolled in the VPTC program. The mean age of participants was 37.9 years, and half (50.8%) were male. The racial distribution showed that nearly half identified as White (49.5%) and 43.1% as African American. Smaller proportions identified as Asian (1.7%), American Indian/Alaska Native (1.1%), or Multiracial (2.0%). Most participants were non-Hispanic (91.2%), with 7.2% identifying as Hispanic. Clinical and follow-up outcomes demonstrated notable improvements. At baseline 40.3% of the population reported suicide ideation as compared to 3.7% at follow-up (91.6% reduction, P < 0.001). The mean score of the PHQ-9 at baseline was 13.6 and at follow-up was 6.6. The reduction was statistically significant (P < 0.001). 68% of patients followed through with enrollment with their post discharge follow-up care.

Table 1 Characteristics among patients enrolled in the virtual psychiatric transition of care program, mean ± SD/n (%).

Characteristics	n = 1382	P value
Age in years	37.9 ± 14.3
Male	702 (50.8)
Ethnicity
Hispanic	99 (7.2)
Non-Hispanic	1261 (91.2)
Unknown	22 (1.6)
Race
African American	596 (43.1)
American Indian/Alaska Native	15 (1.1)
Asian	23 (1.7)
Multi-race	27 (2.0)
Other	3 (0.2)
Unknown	34 (2.5)
White	684 (49.5)
C-SSRS baseline	557 (40.3)
C-SSRS follow-up	51 (3.7)	< 0.001
PHQ-9 baseline	13.6 ± 5
PHQ-9 follow-up	6.6 ± 6.5	< 0.001
Follow-up appointment	940 (68)

C-SSRS: Columbia-Suicide Severity Rating Scale; PHQ-9: Patient Health Questionnaire 9.

Table 2 shows that post-discharge utilization patterns indicate relatively low rates of acute care use. Within 45 days of discharge, 13.0% of patients had a behavioral health acute care encounter (inpatient or Department of Emergency). Within 30 days of discharge, 6.0% of patients were readmitted to an inpatient psychiatric unit. For all-cause, non-elective utilization within 30 days of discharge, 22.4% of patients had at least one inpatient, observation, or Department of Emergency encounter. Specifically, 7.6% had an inpatient stay, 2.7% had an observation visit, and 15.3% visited a Department of Emergency.

Table 2 Post-discharge acute care utilization, n (%).

Utilization	n = 1382
45-day utilization to a Behavioral Health Unit or Department of Behavioral Health Emergency
Yes	179 (13.0)
30-day inpatient psychiatric unit utilization
Yes	83 (6.0)
30-day all cause non-elective utilization
Composite, yes	310 (22.4)
Inpatient, yes	105 (7.6)
Observation, yes	37 (2.7)
Department of Emergency, yes	212 (15.3)

Composite: Inpatient or observation or Department of Emergency visit.

DISCUSSION

The findings suggest that patients participating in the VPTC program had favorable post-discharge outcomes and acute care utilization. The high proportion of participants with reduced C-SSRS (91.6%) and PHQ-9 (48.5%) scores indicate improvement in suicidal ideation and depressive symptoms, respectively. Both measures surpassed the target set at the start of the assessment 80% and 45%. These reductions are clinically meaningful given the high-risk nature of this population transitioning from inpatient to outpatient behavioral health care. Additionally, the 68% follow-up appointment rate demonstrates improved continuity of care, which is a critical component of successful post-discharge engagement. This rate surpassed the established target of 65% and compares favorably to averages for behavioral health follow-up, reported to be between 50%-60%, suggesting that the VPTC program can facilitate outpatient engagement[18].

Acute care utilization rates further support the program’s impact. Only 6% of patients were readmitted to an inpatient psychiatric unit within 30 days, and 13% required behavioral health acute services within 45 days. Both meet the preplanned targets of 6.5% and 13% respectively. These findings indicate that the VPTC program may help mitigate the high rates of rehospitalization typically seen in behavioral health populations, where readmission rates have been reported to exceed 15% within 30 days[19].

There were several lessons learned that would enhance the establishment of a virtual behavioral health program. Regular follow-up and transparent communication with referring facilities were critical for maintaining program engagement and support. Providing consistent updates regarding program outcomes to facility leaders helped sustain buy-in from inpatient units and encouraged ongoing dialogue about successes and areas for improvement. When units were not informed of program progress, they were less likely to recognize its value. Establishing structured communication channels has been key to strengthening collaboration between the inpatient teams and the VPTC program.

Another operational inefficiency was in early implementation. Conducting virtual appointments with patients and inpatient staff proved logistically challenging, as these sessions required staff to step away from their unit responsibilities for extended periods. While face-to-face contact is valuable, alternative methods such as using patient phones or secure rooms for virtual or telephone-based meetings were found to be more practical. These approaches preserved patient engagement while improving workflow and staff efficiency.

Initially, the program offered a single 60-minute “hospital follow-up” appointment type for patients. As the program evolved, two additional appointment types were introduced to address emerging needs. A “follow-up extended” 60-minute visit was added for patients discharged from the behavioral health emergency department who required short-term support prior to connecting with community providers. Additionally, a 30-minute “follow-up” appointment was created for patients needing continued medication management after discharge.

In addition to the lessons learned, several limitations to the program were identified. Patients without reliable access to a phone were unable to engage with the care team. Selection bias may be present as those participating may be more engaged and have better outcomes than those less engaged in follow-up care management programs. Similarly, participation in virtual hospital follow-up appointments was limited for patients without insurance coverage or the financial means to pay the self-pay rate. Additional barriers included the lack of appropriate technology for video visits, such as smartphones or computers with camera capability. The follow-up period is only 45 days but that exceeds the 30 days readmission rate that influences reimbursement. Regression towards the mean may influence the reduction of the PHQ-9 scores. Only a single baseline and follow-up measure were compared. Participation was also contingent on being 18 years and older, which excludes an entire patient population.

While the data suggests strong engagement and symptom improvement, ongoing evaluation should assess the sustainability of these outcomes over longer follow-up periods and their relationship to program intensity, patient characteristics, and social determinants of health. The results of the participants are better than the published benchmarks, but there is no control group for causal inference. The results highlight the success of the VPTC program in enhancing post-discharge stability, symptom reduction, and engagement in follow-up care.

CONCLUSION

The VPTC program is feasible and has shown early positive effects in supporting continuity of care and reducing acute service use. By providing systematic post-discharge outreach, medication management, and care coordination, the program addresses challenges in behavioral health continuity of care. Preliminary outcomes suggest that virtual post-discharge behavioral health programs are feasible in addressing gaps in access, reducing acute care utilization, and supporting patient stability in the community. In addition to traditional clinical services, virtual care may incorporate referrals to evidence-based digital interventions, such as mood tracking devices, digital applications to enhance adherence to medications, and psychoeducational modules[20]. These resources can complement existing services and offer additional strategies to manage symptoms independently. Future directions include evaluating long-term outcomes, examining cost-effectiveness, and identifying strategies to expand the program across additional populations and care settings.

ACKNOWLEDGEMENTS

We acknowledge the behavioral health leadership, providers, and clinicians for their support and willingness to implement new approaches to improve patient care. Additionally, we thank the Duke Endowment and Atrium Health for their financial support of the development and implementation of the VPTC program.