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JPS Health Network Transition Management Program

JPS Foundation

JPS Health Network Transition Management Program Logo

Program Website
Winner Status:
Program Type:
Policy and Systems Change
Target Population:
Individuals with Serious Mental Illness

Program Description

The Transition Management Program at JPS Health Network is a comprehensive discharge program that assists patients in the transition from inpatient behavioral health services back into community care. Behavioral health readmissions account for 17% of all Medicaid 30-day readmissions, with a cost of $832 million. As the public hospital, and only Psychiatric Emergency Center, in the area, behavioral health patients at JPS are at high risk of 30 day readmissions at great local cost. JPS Transition Management Program added Transition Coordinators, who help patients plan for discharge while they are still in care, and also provide transition assistance after they are discharged into the community. JPS also implemented a Readmission Risk Tool for all inpatient behavioral health clients, and offered more intensive transition care from the Transition Coordinators to patients identified at “moderate” or “high” risk of readmission. The Transition Management Program increased the percent of patients who received follow-up care within seven days of discharge from 34% to 57%, and the percent of patients receiving follow-up care within thirty days of discharge from 42% to 60%. Further, 30-day readmission rates dropped by 50%, and the lower readmission rates were consistent when measured at 180 days.


Behavioral health conditions account for four of the ten highest conditions with 30-day readmission rates in both Medicaid and uninsured patient populations, including the top two conditions with the highest readmission rates. JPS completed a chart review and patient interviews and identified the statistically significant predictors of readmission among JPS’ patient population, including certain diagnoses, ages, races, ethnicities, and home zip codes. The patient’s readmission risk score corresponds with a level of transition management provided by an integrated team, including a Social Worker and Peer Support Specialist, which begins while the patient is still in-facility and continues post-discharge. Numerous cycles of continuous quality improvement have identified ongoing improvements, including providing medications in-hand to all patients at discharge instead of them needing to go to a pharmacy.


Other organizations can emulate the JPS Transition Management Program’s process of identifying significant predictors of readmission within their own facilities, and use the risk score to correspond with stepped levels of transition assistance. They can build a multi-disciplinary transition team to provide pre and post-discharge assistance, and can use the modifications identified in JPS’ continuous quality improvement model within their own systems. Further use of the continuous quality improvement model can continue to drive locally-relevant modifications to make significant improvements in patient care and reductions in readmission rates. JPS leaders are disseminating the lessons learned from the Transition Management Program through presentations at the Texas Hospital Association, American Public Health Association Annual Conference, and America’s Essential Hospitals Annual Conference. JPS is also pursuing publication of this project in medical journals.


JPS has paid for the initial Transition Management Program as part of a Texas Medicaid Waiver project. It has also resulted in significant cost savings to JPS for uninsured patients’ readmissions and reducing fees that JPS pays to other psychiatric facilities to care for patients because of a lack of capacity. JPS will sustain this program through these cost savings, adding the Transition Team’s licensed members to insurance credentialing boards to bill for their services, and advocating with Texas Medicaid to pay for peer services and transition management services.


JPS’ Transition Management Program can be fully duplicated and adapted by other behavioral health hospitals and inpatient facilities. Facilities can either use JPS’ model of doing a self-evaluation of the greatest factors for readmission risk in their patients, or utilize the factors already identified for JPS’ patient population. Facilities can use JPS’ Readmission Risk Rate scoring system and corresponding intervention guide to provide stepped care according to readmission risk. Locally relevant interventions can be added to the intervention guide based on each facility’s needs. Facilities could either create a new team to complete Transition Management, or could use existing staff and integrate the transition management into their work flow and each patient’s treatment plan. Continuous quality improvement can be used by each facility to continue to customize the JPS Transition Management Program to best meet the local needs of their patients.


The Transition Management Program increased the percent of patients who received follow-up care within seven days of discharge from 34% to 57%, and the percent of patients receiving follow-up care within thirty days of discharge from 42% to 60%. JPS’ Transition Management Program reduced JPS’ 30-day readmission rates for patients by 50%. Lower than expected readmission rates were also observed 180 days post-discharge compared to the patient population the prior year. The odds of readmission after program implementation was 32% lower than the odds for a comparator hospital with a similar patient population. These results are especially significant for a public hospital and the high-risk Medicaid or uninsured patient population that was served.