1. Wood County Human Services Mental Health Collaboration Executive Sponsors: Kathy Roetter, Director Change Leader: Randall Ambrosius, Treatment Services Manager Kristi Smith, Norwood Social Services Manager Change Member Team: Health Information Services Manager: Pam Martinson

2. AIMS The Big Aim: Reduce hospital readmission to Norwood Health Care Center Little Aim: Reduce cost to agency

3. Change Cycle 1: Collect baseline data Cycle 2: Complete crisis plan with client prior to discharge from Norwood Health Care Center Cycle 3: Crisis planning focused on clients who have had several hospital readmissions Cycle 4: Crisis planning focused on clients who have been hospitalized several times

4. RESULTS Baseline 13% of individuals re-hospitalized prior to start of change project Average re-hospitalization for 5 month cycle is 10.8%

5. Next Step 1. Begin utilizing new CBRF program known as Bridgeway as of October 2014 2. Educate new staff on process to maintain sustainability 3. Look at way to improve crisis planning 1. Reduction on unnecessary paperwork 2. Distribution of crisis planning 3. Utilize teaming process

6. Impact A. Clients are stabilized in their own home Less traumatic Less traumatic B. Staff time is utilized more efficiently C. Reduction in cost to tax payers