Equitable pathways: Reimagining behavioral health care transitions applying a transition of care bundle model

Transitions from inpatient to outpatient care pose significant risks for individuals with behavioral health conditions (BHC), contributing to fragmented care and preventable hospital readmissions. Comprehensive transition of care (TOC) interventions that address both clinical and social needs may improve outcomes in this vulnerable population.

To evaluate the effectiveness of the First Thirty (FT) program, a nurse-led TOC bundle, in reducing hospital readmissions among patients with BHC and/or substance use disorder (SUD).

This retrospective chart review included adults aged 18 to 64 years with Medicaid or no insurance enrolled in the FT program across 10 hospitals from 2022 to 2023. The FT program applied a TOC bundle comprising care coordination, medication support, discharge phone calls, transportation assistance, and wellness resources. Hospitalizations during the 30 days before and after program enrollment were compared, with analyses conducted separately for 2022 and 2023 cohorts.

Among 3079 patients, readmission rates declined significantly after FT enrollment in both cohorts. In 2022, readmissions decreased from 12.7% pre-enrollment to 6.9% post-enrollment, and in 2023 from 8.2% to 3.3% (both P < .0001), despite differences in baseline cohort characteristics.

The FT TOC model was associated with substantial reductions in 30-day readmission, suggesting that structured, nurse-led care coordination can improve transitions and outcomes for patients with BHC and SUD.