Behavioral Health
Inpatient Psychiatric Facility Collaborative Newsletter
July 2018

Recommendations for Transition Communication

Timely and useful information shared between hospitals and aftercare providers is essential for effective continuity of care and can reduce the likelihood of readmissions for behavioral health patients. Transition information that is too late, too much, not enough, or in a format that is suboptimal or even unusable should be avoided. This month, we discuss recommendations that can ensure effective communication for a successful transition following hospitalization.
Recommendations for All Patients:
  • The patient's providers including mental health, primary care, specialists and others, should be notified as soon as possible of an admission and prior to the transition out of the hospital.
  • At every point during care transitions the patient, family and/or caregivers must be aware of the transition plan with appropriate contact information for any care providers. All care providers should know who is responsible at each transition as well.
  • The transition communication responsibilities of the hospital physician should be explicitly stated in policy or in medical staff bylaws.
  • Concise transfer forms with key elements as identified in the MHA Safe Transitions of Care program must be sent with the patient transferring to post-acute sites of care such as acute rehabilitation, skilled nursing facilities or transitional care facilities (
  • When a patient transfers from one facility to another, direct verbal reports between nursing staff should take place.
  • Complete transition summaries should be received by the accepting facility within five business days or within adequate time to be available for the initial follow-up appointment.

IPF Surveys and Onsite Visits

Thank you to everyone who has participated in an onsite visit and completed the IPF survey. Your feedback has been helpful and will be essential in planning the next steps of our readmission reduction work. If you have not completed the survey, it is not too late. The survey takes less than five minutes and can be completed by clicking on the link below:
IPF Collaborative Call

One of the most frequent requests received from the IPF survey was the desire to learn more about Behavioral Activation. For that reason, we will provide training on Behavioral Activation during the July IPF Collaborative Call. The training will be available via a webinar format. Please feel free to invite any staff members that could benefit from this training.
Mark Your Calendars for this Important Date
Tuesday, July 31, 2018
1:00-2:00 pm EST
Access Code: 5273638
Introduction to Behavioral Activation: Reactivate Patients Transitioning From Hospitalization
  • Introduce Behavioral Activation (BA)
  • Explore the benefits of using Behavioral Activation
  • Develop understanding of the techniques in Behavioral Activation
  • Identify the strategies to align transition planning with Behavioral Activation skills


This material was prepared by Alliant Health Solutions, for Alliant Quality, the Medicare Quality Innovation Network - Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication: 11SOW-AHSQIN-G1-18-42