Closing the Post-Discharge Gap in Veteran Mental Health Care

Impact Statement

Developed a systems-level strategy to reduce post-discharge suicide risk by strengthening continuity of care, aligning resources with patient risk, and addressing breakdowns in transitional support.

Overview

This analysis examines how gaps in post-discharge coordination contribute to elevated suicide risk among veterans. While access to care has expanded, transitions between emergency, inpatient, and outpatient systems remain fragmented—creating critical failures in follow-up, accountability, and patient engagement. This work reframes the problem as one of continuity, not access alone.

Core Insight

The system is not failing from lack of intent, but from lack of continuity.Current systems are designed to treat acute episodes, but not to manage what happens between them. As patients transition across levels of care, responsibility diffuses, communication weakens, and engagement declines during the most vulnerable period.

System Breakdown

• Inconsistent discharge planning across facilities

• Weak coordination between ER, inpatient, and outpatient teams

• Limited structured follow-up during high-risk windows

• Staff burnout reducing attention, empathy, and risk recognition

• Patient disengagement due to lack of clarity and support

Strategic Application

This work proposes a multi-layered continuity model:

• Risk Stratification: Prioritize high-risk patients at discharge using predictive indicators, integrating AI-based suicide risk models developed in veteran health system research

• Continuity Layer: Introduce dedicated follow-up support to maintain engagement post-discharge

• Staff Systems: Strengthen communication, accountability, and culture across care settings

Implications

Shifting from reactive to continuous care improves patient visibility, strengthens trust, and reduces missed interventions. This approach aligns clinical resources with real-world patient behavior—ensuring systems function effectively beyond acute treatment settings.