Improving discharge follow-up post-hospitalization via nurse led interventions at a certified community behavioral health clinic (CCBHC)

This quality improvement project addresses the critical issue of low follow-up rates after psychiatric hospitalization at a rural Certified Community Behavioral Health Clinic (CCBHC), where only 47% of patients received follow-up within 7 days. Given the significantly elevated suicide and readmission risks during the post-discharge period, the project implements a nurse-led intervention grounded in the Institute for Healthcare Improvement’s Model for Improvement and care transition theory. The aims were to increase 7-day follow-up rates to 75% and reduce 30-day readmission rates from 67% to 40% by January 2026. The intervention involved structured nurse-led follow-up visits within 7 days of discharge, with contact protocols and documentation integrated into the Epic EHR.