Shawano County Niatx 2018 Project

Small Aim Reduce number of 90 day readmits from 15% in 2017 to 10% in 2018

Change Increase crisis case management Connect with consumer prior to d/c from hospital to have first face to face contact scheduled At least one face to face contact per week post d/c until connected Multiple phone contacts Increase Referrals to Community Mental Health More case management from CMH case managers

Results 2017 (whole year) 2018 January- October 1st 140 Total Hospitalizations Total readmits- 22 Less than 30 day readmits- 13 Over 30 day readmits- 9 Total number of clients readmitted- 17 (5 in CMH) Number of recommits due to non-compliance- 13 147 Total Hospitalizations Total readmits- 20 Less than 30 day readmits- 11 Over 30 day readmits- 9 Total number of clients readmitted- 12 (8 in CMH) Number of recommits due to non-compliance- 16 We increased our contacts within the first 30 days to one face to face each week and at least two phone contacts with client’s d/c from inpatient and maintained contact with clients until connected to therapy or CMH referrals. Actual data- 15.5% in 2017 and 13% in 2018 Interesting points- only 12 individuals readmitted and 8 of those individuals are already or now enrolled in Community Mental health programs Our individuals on a SA or Commitment and were a return on order account for 16 of the 20 recommits in 2018 Data shows that we already have a significant increase in total admissions from the previous year, but the number of readmits remains the same and less client’s are being readmitted. Of those being readmitted, majority are being readmitted due to failure to comply with their court orders in not taking their medications or not refraining from alcohol or other substances.

Next Steps- Adapt case management efforts Continue to provide more intensive follow up services starting at making contact while consumer remains IP Collaborate with CMH to have more client’s enrolled in CMH programs to help with intensive CM CMH case managers continue to increase their face to face contacts to support and prevent crises

Impact Number of clients returning IP is decreasing, although the high needs clients are returning IP more frequently Creates conversation, collaboration, and program adjustments to best support those high needs consumers Increase in crisis referrals over past three years 2016- 489 2017- 523 2018 (1/1-10/1) -433 Diversion numbers- 2016- 58 days 2017- 135 days 2018- 370 days and counting Cost impact- IP fees decrease as CMH consumers have MA