<![CDATA[ABSTRACT High readmission rates among Patients with Mental Disorders (ODGJ) are often linked to Discharge Planning (DP) failures. This study aims to deeply explore systemic barriers and the need for community-based solutions to prevent DP from functioning as an effective Transitional Care (TC) mechanism at Naimata Mental Hospital, Kupang. This descriptive phenomenological qualitative research involved 14 key participants (Mental Hospital Health Personnel, Community Health Center Nurses, ODGJ Patients, and Families/Caregivers) through In-depth Interviews. Data were analyzed using thematic methods to identify major barriers in the post-discharge continuum of care. Eight main themes were found, which include: (1) Massive handoff failure, manifested as "Silent Discharge" due to the absence of formal coordination (WA Group) between the Mental Hospital and Community Health Centers (Puskesmas). (2) Medication non-adherence is triggered by Social Determinants of Health (SDH), especially the "Medication vs. Food" dilemma and high transportation costs. (3) Families experience an extreme Caregiver Burden crisis, inducing High Expressed Emotion (EE) due to inadequate Family Psychoeducation (FPE). (4) The analysis justifies the need for the SEHATI Collaborative Model as a bridging mechanism. Service fragmentation, coupled with unaddressed SDH and high Caregiver Burden, drives readmission. The SEHATI Model is recommended to formalize coordination, integrate local initiatives (Gentar Sejiwa), and provide holistic psychoeducation to prevent relapse. Keywords: Discharge Planning, Handoff Failure, Caregiver Burden, Social Determinants of Health, SEHATI Model. ABSTRAK Angka readmisi yang tinggi pada Pasien Dengan Gangguan Jiwa (ODGJ) sering dikaitkan dengan kegagalan Discharge Planning (DP). Penelitian ini bertujuan mengeksplorasi secara mendalam hambatan sistemik dan kebutuhan solusi berbasis komunitas yang mencegah DP berfungsi sebagai mekanisme Transitional Care (TC) yang efektif di RS Jiwa Naimata Kupang. Penelitian kualitatif fenomenologi deskriptif ini melibatkan 14 partisipan kunci (Tenaga Kesehatan RSJ, Perawat Puskesmas, Pasien ODGJ, dan Keluarga/Caregiver) melalui In-depth Interview. Data dianalisis menggunakan metode tematik untuk mengidentifikasi hambatan utama dalam kontinum layanan pasca-pulang. Ditemukan delapan tema utama, yang menunjukkan: (1) Kegagalan handoff yang masif, termanifestasi sebagai “Pulang Senyap” (Silent Discharge) karena ketiadaan koordinasi formal (WA Grup) antara RSJ dan Puskesmas. (2) Non-adherence obat dipicu oleh Determinan Sosial Kesehatan (SDH), terutama dilema "Obat vs. Nasi" dan tingginya biaya transportasi. (3) Keluarga mengalami krisis Beban Caregiver yang ekstrem, memicu High Expressed Emotion (EE) akibat kegagalan Family Psychoeducation (FPE). (4) Analisis memvalidasi kebutuhan Model Kolaboratif SEHATI sebagai mekanisme penghubung. Fragmentasi layanan, ditambah SDH yang terabaikan dan Caregiver Burden tinggi, mendorong readmisi. Model SEHATI direkomendasikan untuk memformalkan koordinasi, mengintegrasikan inisiatif lokal (Gentar Sejiwa), dan memberikan psikoedukasi holistik guna mencegah kekambuhan. Kata Kunci: Discharge Planning, Kegagalan Handoff, Beban Caregiver, Determinan Sosial Kesehatan, Model SEHATI.]]>
