Closing the Post-Discharge Gap in Veteran Mental Health Care

Impact Statement

Developed an applied systems strategy and proposed evaluation framework to reduce post-discharge suicide risk among veterans within the first 7–14 days following care transitions. This approach strengthens continuity of care, aligns resources with patient risk, and addresses breakdowns in transitional support across clinical settings.

Overview

This analysis examines how gaps in post-discharge coordination contribute to elevated suicide risk among veterans, particularly within the first 7–14 days following discharge—a period consistently associated with heightened vulnerability. While access to care has expanded, transitions between emergency, inpatient, and outpatient settings create multiple opportunities for critical information, accountability, and follow-up to become fragmented. These gaps represent a significant barrier to timely and effective suicide prevention interventions across levels of care.

This work reframes the challenge as one of continuity across the care continuum, rather than access alone.

Core Insight

The system is not limited by lack of intent, but by gaps in coordinated follow-through. 

Current care models are designed to stabilize acute episodes, but are less structured around managing what occurs between them. As patients transition across care settings, responsibility can become diffuse, communication pathways may weaken, and patient engagement often declines during the highest-risk period.

System Breakdown

• Variability in discharge planning processes across facilities

• Gaps in coordination between ER, inpatient, and outpatient care teams

• Limited structured follow-up during the 7–14 day high-risk window

• Operational strain and staff burnout impacting consistency and risk recognition

• Patient disengagement driven by unclear next steps and limited continuity of support

Strategic Application

This work proposes a multi-layered continuity model designed for implementation and evaluation:

• Risk Stratification: Identify and prioritize high-risk patients at discharge using clinical indicators and integrating AI-based suicide risk prediction models informed by veteran health system research

• Continuity Layer: Establish structured follow-up protocols within the first 7–14 days, including defined ownership, proactive outreach, and continuity touchpoints to maintain engagement

• Staff Systems: Implement clear communication pathways, standardized transition protocols, and role-based accountability across care settings to support coordinated follow-through

Implications

The goal of this approach is to improve the quality of care, reduce gaps in follow-up services, and ensure patients remain visible and supported during the most vulnerable post-discharge period.

By shifting from a reactive to a continuous model of care, this framework supports a more collaborative, adaptive, and transparent system—one that aligns clinical resources with real-world patient needs and strengthens the reliability of care across transitions.