Date of Conferral

8-21-2026

Date of Award

August 2026

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Jonas Nguh

Abstract

This doctoral project was a nursing led quality improvement initiative focused on standardizing discharge planning on an adult inpatient psychiatric unit. The goal of the project was to strengthen evidence-based, person-centered transitions of care to reduce readmissions and promote safer community reintegration for adults with serious mental illness. The practice focused question guiding this project was whether implementing an evidence based, standardized discharge planning protocol on an adult inpatient psychiatric unit would improve staff knowledge and adherence to best practice discharge elements and contribute to a favorable decrease in 30-day readmission rates. Analytical strategies included descriptive analysis of pre and post education staff questionnaire data, an audit of protocol adherence for eligible discharges, and comparison of unit level 30 day readmission rates before and after implementation, informed by contemporary approaches to readmission reduction and value based care. Findings indicated that staff demonstrated improved knowledge and confidence in evidence based discharge practices following education, and audit data showed increased completion of key elements, such as documented follow up appointments, medication teaching, and individualized safety plans, consistent with outcomes reported in recent psychiatric discharge planning projects. By standardizing discharge processes while tailoring education and follow up to each patient’s cultural, linguistic, and social context, this project supports positive social change and advances diversity, equity, and inclusion, helping to reduce disparities in post discharge outcomes among individuals living with serious mental illness. Background Psychiatric patients with serious mental illness experience high 30 day readmission rates, often ranging from 20% to 40%, which disrupt recovery, burden families, and increase costs for health systems (Smith et al., 2021). Despite these risks, studies have shown that 30%–50% of adults discharged from psychiatric units never attend a follow up mental health appointment within 30 days, highlighting a persistent gap in continuity of care at the transition from hospital to community (Smith et al., 2021). The high 30 day readmission rates that psychiatric inpatients experience make effective transitions of care a critical nursing responsibility. Recent literature has demonstrated that structured, person centered discharge and transitional care interventions improve continuity of care, medication adherence, and functional outcomes for individuals with serious mental illness and can reduce unplanned readmissions (Dhaliwal & Dang, 2024).The goal of the project was to strengthen nursing led discharge practices using current best practice guidance on transitions of care and social determinants of mental health, thereby supporting safer, more equitable community reintegration for adults hospitalized with serious mental illness. At the doctoral project site, leadership identified inconsistent, non-standardized discharge planning processes across clinicians, variable documentation of safety plans and follow up, and limited attention to social determinants of health as key contributors to avoidable readmissions and unsafe transitions in care. This practice gap underscored the need for a structured, nursing driven discharge planning protocol that can reliably support safe, equitable, and person centered transitions for adults hospitalized in psychiatry hospitals. The practice focused question guiding this project was whether implementing an evidence based, standardized discharge planning protocol on an adult inpatient psychiatric unit would improve staff knowledge and adherence to best practice discharge elements and contribute to a favorable decrease in 30-day readmission rates. The purpose of the project was to enhance nursing practice in discharge planning by integrating current evidence on transitional care, continuity of follow up, and social needs screening into a practical protocol and checklist that can be embedded in everyday workflow. Evidence supporting this change comes from observational and experimental studies showing that when outpatient appointments are scheduled as part of inpatient discharge planning, patients are 2 to 3 times more likely to attend mental health follow up within 7–30 days (Balasubramanian et al., 2025). Previous research on transitional interventions for adults discharged from psychiatric units indicated that multicomponent approaches, including predischarge education, structured needs assessment, coordination of follow up, and improved communication between impatient and community providers, can meaningfully reduce early psychiatric readmissions and improve continuity of care (Cabello-Rangel et al., 2024). Emerging work on social determinants of health has demonstrated that factors, such as poverty, unstable housing, social isolation, and limited community supports, are strongly associated with increased readmission risk, suggesting that discharge planning must also systematically identify and addresses social needs to be effective and equitable (Cai et al., 2025). Overall, the strength of the evidence supporting standardized, person centered discharge planning and improved transitions of care for psychiatric inpatients can be rated as moderate. Multiple systematic reviews, cohort studies, and quasi experimental projects consistently showed improvements in follow up engagement and, in many cases, reductions in readmissions, but variability in intervention components, study designs, and settings limits the ability to draw definitive causal conclusions (Tyler et al., 2023). Nonetheless, this body of evidence provides a strong rationale for implementing a structured discharge planning protocol as a nursing practice change to address the documented gap in discharge processes and continuity of care at the project site (see Phillip et al., 2022) Project Development The primary outcome variables for this evaluation were: (a) staff knowledge and self reported confidence in evidence based discharge planning practices, measured with a pre and post education questionnaire; (b) adherence to key discharge process element captured on the standardized checklist (e.g., documented follow up appointment within 7 days, medication education with teach back, individualized safety/crisis plan, and social needs screening); and (c) unit level 30 day psychiatric readmission rates for adult discharges. These variables aligned with current literature that recommended evaluating both process measures (i.e., completion of best practice elements) and patient outcomes when implementing discharge planning interventions in psychiatric settings (see Imhof et al., 2025). I obtained unidentified data from existing sources in accordance with site and university approvals. Staff survey responses were collected anonymously using paper. Discharge process data were abstracted through structured chart audits of adult inpatients discharged from the unit, using a standardized tool to record whether each checklist element was completed. I obtained 30 day readmission data in aggregate form from the hospital’s quality/analytics department for the same unit, with the department providing monthly counts and rates of unplanned psychiatric readmissions rather than patient level identifiers. The pre-implementation comparison period consisted of 3 months of discharges before the intervention start date, and the postimplementation period consisted of 3 months of discharges after full implementation of the protocol. Results Postimplementation data showed improvement in both staff and patient level outcomes associated with the standardized discharge planning protocol. Staff post education questionnaires demonstrated higher mean scores for knowledge and confidence in evidence based discharge practices compared with pretest scores, indicating that the education and checklist clarified expectations for safe, person centered discharge planning. Chart audits during the implementation period showed increased completion of key processes, including documented 7 day follow up appointments, medication teaching using teach back, individualized safety plans, and screening for social needs relative to the pre-implementation period, consistent with recent quality improvement projects that implemented structured behavioral health discharge tools. At the unit level, 30 day psychiatric readmission rates declined modestly in the months after implementation (from 22% to 20%), mirroring evidence that multicomponent discharge and transitional care interventions, including post discharge contact, can lower early readmissions for psychiatric inpatients (see Phillip et al., 2022). Table 1 includes the pre and postimplementation results for staff knowledge scores, checklist adherence percentages, and monthly 30 day readmission rates for the adult psychiatric unit. Table 1 Outcomes for 30 Day Psychiatric Readmissions and Discharge Process Measures Outcome measure Reimplementation value Postimplementation value 30 day psychiatric readmission rate (%) 22 20 Follow up appointment scheduled within 7 days (%) 60 75 Medication teaching with teach back documented (%) 55 72 Individualized safety/crisis plan documented (%) 50 70 Social needs screening completed (%) 45 61 For the organization, these findings indicate that the standardized discharge protocol made discharge processes more consistent and may help the unit use beds more efficiently by slightly lowering unplanned readmissions. This nursing led change aligns with national readmission reduction incentives and mirrors other behavioral health projects that have improved patients’ satisfaction with discharge teaching and readiness for transition (see Lin et al., 2024). Even though the decrease in readmissions was modest, it is an important step toward safer, more coordinated care and may ultimately improve quality metrics, costs, and staff role clarity. Several limitations affected the results and their interpretation. The project was conducted on a single, adult, inpatient psychiatric unit with a relatively small number of discharges, limiting statistical power and generalizability. This is a common constraint noted in behavioral health quality improvement literature (Imhof et al., 2025). For evaluation, I used a pre-/post education design without a control unit, so staffing changes or other organizational initiatives could have influenced readmission rates and process measures independent of the protocol. Implementation occurred over a relatively short time frame, and protocol adherence varied, which could have affected the true effect of a fully embedded discharge planning model. Finally, I cannot be sure whether the small change in readmissions is due to the discharge protocol, or partly due to having a slightly “easier” patient group (e.g., less severe illness, more stable housing) in the post education period. Despite these limitations, the project is important beyond the local site because it collected current evidence on psychiatric transitions of care into a practical, nurse driven protocol that can be adapted to other inpatient behavioral health units and outpatient mental health programs. Recent reviews and quality improvement projects have emphasized that scalable discharge planning solutions must address both clinical and social needs, incorporate structured follow up, and be feasible within routine workflow features reflected in this project’s checklist and processes (Brom et al., 2024). The project’s implications for nursing practice include strengthening the nurse’s role in coordinating person centered, interdisciplinary discharge planning; systematically addressing social determinants of health that affect community stability; and using data to drive continuous improvement in psychiatric transitions of care. Conclusions This project strengthened the organization’s discharge processes by making them more consistent, patient centered, and aligned with current expectations for safe transitions of care, while showing early signs of reducing 30 day psychiatric readmissions and improving follow up linkage. Further work should include sustaining the checklist through electronic health record integration, extending the protocol to other behavioral health units, and adding structured post discharge contacts for high risk patients. For nursing, the project reinforces the advanced practice role in coordinating holistic discharge planning that addresses clinical needs, social determinants of health, and culturally responsive education, thereby supporting positive social change through safer community reintegration, reduced crisis utilization, and more equitable outcomes for diverse individuals living with serious mental illness. References Balasubramanian, I., Andres, E. B., & Malhotra, C. (2025). Outpatient follow-up and 30-day readmissions. JAMA Network Open, 8(11), e2541272. https://doi.org/10.1001/jamanetworkopen.2025.41272 Cabello-Rangel, H., Estrada-Martínez, M., & Martinez-Torres, M. (2024). Factors associated with readmission within 30 days of hospital discharge of psychiatric patients: Case-control study. Actas Españolas De Psiquiatría, 52(4), 405–411. https://doi.org/10.62641/aep.v52i4.1651 Cai, Y., Yanping, L., & Liu, Q. (2025). Social determinants of health and 30-day readmission for heart failure patients in U.S. hospitals: Evidence from ICD-10 z-code data. Healthcare, 13(17), 2102. https://doi.org/10.3390/healthcare13172102 Dhaliwal, J. S., & Dang, A. K. (2024). Reducing hospital readmissions. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK606114/ Imhof, L., Heber, R., Blume, K. S., Schreyoegg, J., & Winter, V. (2025). Hospital discharge planning—An investigation of outcomes and interventions. Health Services Research, 61(1), e70060. https://doi.org/10.1111/1475-6773.70060 Lin, L., Fang, Y., Wei, Y., Huang, F., Zheng, J., & Xiao, H. (2024). The effects of a nurse-led discharge planning on the health outcomes of colorectal cancer patients with stomas: A randomized controlled trial. International Journal of Nursing Studies, 155, 104769. https://doi.org/10.1016/j.ijnurstu.2024.104769 Phillip, A., Rossi, G., & DeSilva, R. (2022). Stopping the revolving door: Reducing 30-day psychiatric readmissions with post-discharge telephone calls. Cureus, 14(1), e21174. https://doi.org/10.7759/cureus.21174 Smith, T. E., Haselden, M., Corbeil, T., Wall, M. M., Tang, F., Essock, S. M., Frimpong, E., Goldman, M. L., Mascayano, F., Radigan, M., Schneider, M., Wang, R., Rodgers, I., Dixon, L. B., & Olfson, M. (2021). The effectiveness of discharge planning for psychiatric inpatients with varying levels of preadmission engagement in care. Psychiatric Services, 73(2), 149–157. https://doi.org/10.1176/appi.ps.202000863 Tyler, N., Hodkinson, A., Planner, C., Angelakis, I., Keyworth, C., Hall, A., Jones, P. P., Wright, O. G., Keers, R., Blakeman, T., & Panagioti, M. (2023). Transitional care interventions from hospital to community to reduce health care use and improve patient outcomes. JAMA Network Open, 6(11), e2344825. https://doi.org/10.1001/jamanetworkopen.2023.44825

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