Introduction The overcrowded and overstimulating Emergency Department (ED) is ill-suited to the needs of people experiencing a mental health crisis and risks exacerbating distress. To reduce ED presentations and facilitate care transitions, the role of Transition Coordinator (TC) nurse was created. However, people receiving case management continued to attend ED, experiencing mental distress and needing admission.

Aim/Question This mixed methods study explores the lead-up to these admissions to identify barriers to proactive care transitions.

Method Retrospective review of community mental health service clinical records for the 12 months preceding all unexpected admissions via ED in 2023.

Results Themes included difficulty engaging with services, gaps in knowledge of case managers, support workers, and systemic issues including limited hours of service and recent hospital discharge.

Discussion The study highlights the need for integration between hospital and community mental health services, the importance of crisis management planning, and the need for services to work together to smooth care transitions.

Implications Understanding factors associated with unexpected mental health deterioration allows care providers to modify practice and develop services that facilitate seamless care transitions and provide care matched to individual need.

Recommendations Integrated mental health services should consider the quality of care transitions, communication between different arms of the service, early identification of people at risk of mental health crisis, and access to services outside business hours.