1. Mark Johnson, MSW mandy Woodward, BSN, RN
Brown County NIATx 2017
Mark Johnson, MSW
mandy Woodward, BSN, RN

2. Objective
To increase the number of post-inpatient contact for those identified as high-risk for re-admission

3. April-June 2017: 15 individuals under case management who had a re-admission Total of 27 out of 172 admissions 15.69% readmission rate
Pertinent Data
Out of the 15 clients, 9 were placed in either long term care or CBRF setting. six clients were returned to their home with on-going support.

4. Pertinent Data
July-September 2017: 5 readmissions for case-managed clients Total of 9 out of 192 readmissions 6.25% readmission rate
Out of the 5 clients, 1 person had fled the state and was returned. 1 was an attempt to transition into own apartment after many years in structured settings.

5. INTERPRETATION OF DATA AND NEXT STEPS
Significant decrease in readmissions from the first to second quarter
15.69% down to 6.25%
No specific rationale noted for decrease
QAPI PLAN INITIATED IN ORDER TO TRACK READMISSIONS AND MAKE IMPROVEMENTS WITHIN INPATIENT AND OUTPATIENT
Discharge Planning Committee
Readmission Reviews
Checklists in charts for case-managed clients to improve communication between inpatient and outpatient staff

7. Review each readmission and collect data on common themes
Review each readmission and collect data on common themes. Focus on developing preventable measures that will be addressed in discharge planning.