1. Shawano County
Niatx 2018 Project

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

3. 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

4. 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.

5. 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

6. 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
2018 (1/1-10/1) -433
Diversion numbers-
days
days
days and counting
Cost impact- IP fees decrease as CMH consumers have MA