1. NIATx Project 2012

2.  BIG AIM: Reduce (re-) hospitalization due to gaps in service delivery when consumers’ needs are immediate, multiple and/or exceed existing plan of care.  LITTLE AIM: Create a plan to evaluate and assist consumers within 48 hours (to reduce duplication of services, staff time, and that is person centered.)

3.  Identify “gaps” that delay or create confusion when consumers needs are multiple and complex  Review cross unit collaboration (communication barriers when multiple staff within SCDHS are contacted to provide intervention)  Increase timeliness of SCDHS staff to determine family resources and needs and improve stability in our local community

4.  Created job position to provide comprehensive clinical assessment for consumers with complex and multiple needs  Training of all SCDHS staff in collaboration and team process  Monthly meetings of administration and staff to build plan for improving intra-agency collaborative/team response  Built flexible spending option to support stabilization within our local community

5.  Time of service (initial contact 24/48 hours)  Time of family driven support plan (initial family assessment completed within 30 days)  Engagement in team services (minimum of 6 months or when team determines lower risk levels are achieved)  Reduce hospitalizations  Increase number of crisis plans (within 30 days of initial contact)

6.  Hire new employee – 1/1/2013  Select (or develop) family assessment tool(s) – 2/1/2013  Develop consumer satisfaction survey – 2/1/2013  Review random selection of case files to tract outcome targets– 7/1/2013  Continue monthly meetings of administration and staff to build plan for improving intra- agency collaborative/team building