1. Waukesha County DHHS Clinical Services Division

2. Project Aims Reduce the number of patients readmitted within 30 days of hospital discharge. 2009 readmission rate was 9.45% Increase the percentage of first outpatient appointments kept. 2009 rates: ₀ 75% of therapist appointments ₀ 70% of psychiatrist appointments

3. Changes Streamlined discharge teaching: Patients receive a one sheet summary of discharge information. Formalized day of discharge “check outs”: Patients meet with their social worker and nurse to review appointments, crisis plan, community resources and medications. Follow-up phone calls within 3 days of discharge by crisis worker: Review discharge information Identify and eliminate barriers to successful transition to outpatient services Provide crisis intervention if needed

4. Results 30 Day Readmissions baseline test return to baseline

5. Results First Outpatient Appointment Kept

6. Next Steps/Impact Sustain process improvement. Adopt discharge instruction sheet and “check outs”. The changes simplify and organize discharge instructions and reinforce the importance of post-hospital care. Shift focus from global process improvement to an individual case-based review. Case-by-case review of reasons for readmission with patients readmitted within 30 days of discharge.