Discharge planning can be challenging for all hospitals, but for those coordinating behavioral health patients, it can be especially difficult.
Leaders told Becker’s that behavioral health patients often face worse barriers to aftercare than traditional medical patients. Some patients need to be discharged to group home facilities, many of which do not accept patients with extensive behavioral health histories. Many patients require assistance beyond medical care, including food and housing assistance. All of these barriers, and more, make discharge planning tricky as hospitals work to move patients to a lower level of care.
“Discharge planning should be viewed as a continuation of care, not a conclusion,” Stacey Romero, director of behavioral health and clinical integrated services at Santa Fe, N.M.-based Presbyterian Medical Services, told Becker’s. “The goal is to set patients up for long-term stability and recovery. If we see it as a conclusion, we’re not leaving space for patients to continue their journey.”
Here, leaders at six hospitals across the nation share their best practices for behavioral health discharges.
Editor’s note: Responses have been lightly edited for clarity and length.
Deborah Boggs, MSN, RN. Director of Nursing at Stonebridge Behavioral Hospital (Lake Charles, La.): There are several challenges when coordinating hospital discharges from behavioral health hospital stays. There are times when there are no good solutions, as when the disease course has resulted in significant barriers to relationships with natural carers or engaging treatment. Our crisis stabilization framework contributes to this, unfortunately. First, discharge planning begins at the time of admission, with identification of supports, barriers, personal strengths and weaknesses, current community resources, as well as the remainder of the multidisciplinary assessment.
Second, discharge patients with their prescribed medications, as well as an additional refill. This will help to maintain medication adherence until they are able to see their clinician. When possible, having a scheduled appointment post discharge, when possible, can be appropriate.
Finally, engage the support of friends or loved ones when the patient allows it. This is often a barrier due to disease process, substance use or the consequences of prior behavior. But when allowed by patients, it can be the difference between stability and continued symptom exacerbation.
Barbara-Ann Bybel, DHA, MSN. Vice Chair Psychiatry Hospital Services and Integration, and Director of Psychiatry Services at UNC Neurosciences and Youth Behavioral Health (Butner, N.C.): At UNC Hospitals, we adhere to Complex Case Reviews. Discharge planning begins on admission, and we focus early on addressing potential barriers. CCR is an interdisciplinary intervention implemented to proactively address barriers to care and discharge for high-acuity patients. Facilitated by social work leadership, the rounds are held weekly and include psychiatry, social work, nursing leadership, psychology, pharmacy, utilization management and others. Cases are selected based on illness complexity, prolonged length of stay, readmission or active 1:1 staffing needs. The goal is to provide structured peer consultation and mobilize coordinated strategies to support clinical decision-making, facilitate timely disposition, and escalate system-level barriers. Action pathways have been defined to engage community care coordinators, guardians, and state hospital transfer resources when standard planning efforts stall.
We also work to close identified gaps in levels of care. The UNC IOP Proactive Referral Review Program is designed to ensure eligible inpatients are systematically identified and referred to Intensive Outpatient Programs before discharge. By embedding proactive referral reviews into discharge planning, this intervention facilitates smoother transitions to step-down care, reduces readmission risk, and supports timely discharge. The program also strengthens coordination between inpatient teams and outpatient services, improving continuity of care for patients with ongoing behavioral health needs.
Overall, being proactive, decreasing stigma and including patients and caregivers in conversations from the start are all best practices around discharge planning from behavioral health inpatient units.
Amanda Drake, MHA. Manager of Clinical Services of the Crisis Center and Inpatient Mental Health Unit at Dayton (Ohio) Children’s Hospital: Best practice for discharge planning in inpatient pediatric mental health units is a multifaceted approach that truly begins the moment a youth is admitted, not just when their stay is ending. It’s about building a bridge to continued success, setting the stage for a smooth transition back into their lives. From day one, the focus is on what comes next: whether that involves transitioning to a day treatment program, connecting with outpatient therapy and medication management, or accessing other vital community resources.
A critical component of this process is engaging and coordinating with everyone already involved in the youth’s life. This includes current mental health providers, community partners, family and their school. Often, a care conference is held to facilitate this collaborative discharge planning, ensuring all voices are heard and a comprehensive plan is developed. Ensuring all these stakeholders are on the same page and actively collaborating is paramount for a seamless transition. The goal is to create a unified support system that helps the youth re-integrate effectively. Perhaps one of the most crucial elements of best practice in discharge planning is emphasizing the importance of consistent follow-up to both the youth and their caregivers. Continued support after leaving the unit is what truly solidifies their progress and empowers them to thrive in their home environment.
Ben Johnson, DHSc. Director of Behavioral Health Provider Practices and Operations at Lakeland (Fla.) Regional Health: Effective discharge planning in inpatient behavioral health care begins on day one. It requires a patient-centered, multidisciplinary approach that accounts for clinical stability and real-world factors like housing, transportation and outpatient engagement. Inpatient teams must be proactive but flexible, especially when treating patients with limited or unreliable support systems. Many patients we serve have no family involved, are estranged from loved ones or are too ill to recall important personal details. As new information emerges from the patient or collateral sources, discharge plans often shift dramatically. Agility and responsiveness are essential for discharge planners in today’s behavioral health landscape.
One of our most persistent barriers to timely discharge is the lack of placement options for patients who are psychiatrically stable but require assisted living or group settings. Many facilities exclude individuals with serious behavioral health histories, which leads to extended inpatient stays. The wide geographic footprint we serve also makes it challenging to establish consistent relationships with local outpatient providers. One idea I believe could meaningfully address these challenges is the creation of regional behavioral health navigation centers. Unlike admission-focused central receiving facilities, these centers would support the discharge side of care. They would be responsible for maintaining current data on outpatient provider availability, coordinating referrals, and building sustained relationships with community resources on behalf of hospitals, clinics and primary care providers. This could streamline transitions, reduce the length of stay, and ensure patients are connected to the right level of care more efficiently.
Sherri Landry, RN-BSN. Director of Behavioral Health Services at Heywood Hospital (Gardner, Mass.): I believe best practices for inpatient behavioral health discharge planning start with engaging patients at the point of admission to afford them the ability to participate in developing their care plan. Early engagement with patients builds rapport and fosters a trusting environment, laying the foundation for successful discharge planning. Patients who feel heard and supported are more likely to actively participate and follow through with post-discharge services.
Connecting early on with outpatient providers and state agencies is vital TO promoting continuity of care and maximizing resource availability. Involving natural support people (family, friends, religious community, etc.) in the discharge planning process can have a significant impact in a successful transition back to the community. Reviewing outpatient treatment expectations, recommendations, resources, and safety plans with the patient AND natural support people can help ensure that the patient will actually be able to utilize resources after returning to the community. Additionally, it is important for the patient’s identified natural supports to be able to recognize warning signs and know how to access behavioral health crisis resources if needed. Frequent crises and readmissions tend to occur when a patient does not have appropriate outpatient support, or refuses outpatient support. When inpatient behavioral health units work in tandem with outpatient stakeholders to develop discharge plans, it provides the “warm handoff” that typically results in greater probability patients will fully engage in outpatient support.
The discharge plans with the most successful outcomes are typically developed as patient-centered, focused on safety, foster continuity of care and support the transition back into the community.
Stacey Romero. Director of Behavioral Health and Clinical Integrated Services at Presbyterian Medical Services (Santa Fe, N.M.): I’m bringing this from the perspective of an outside provider, not someone who works in a hospital or inpatient unit. I’m looking at it through that lens. Best practices start with keeping the patient at the center of the process. Discharge planning has to begin at admission and be woven into the treatment journey. That helps normalize the idea of follow-up care and builds patient understanding and comfort with what’s coming next. A proactive approach is always best — one that’s grounded in strong relationships with community providers. That enables the treatment team to coordinate from multiple angles and ensure a warm handoff, whether virtual or in person, so it feels seamless and supportive rather than abrupt.
Another key piece is that the discharge process has to include a thorough needs assessment early in the patient’s stay, with continual updates as treatment progresses. That assessment shouldn’t just focus on their needs while inpatient — it also has to address anticipated needs after discharge: follow-up appointments, housing, transportation, medications, and other support systems. This creates a smoother transition from inpatient to outpatient care. When patients begin to see how all the pieces fit together, it becomes easier for them to understand the importance of continuing care, and they’re more likely to engage after discharge.
