Project workgroup *Change Leaders: Kim Lewis, Kim Packee, Carol Thomas

*Members: Phil Sweet, MD; Shanna Her, SW; Jen Johnson, RN; Miah Olson, SAC; Tina Klemmer, Admissions/Registrar; Erin Sarauer, Civil Services Director; Beverly Pezewski, HIM Director; Bonnie Purtell, QM Director

*Executive Sponsor: Tom Speech Ph.D.

“Reduce the percentage of civil patients who are discharged and re-admitted to a state institution within 30 days, through implementing a quality improvement process that continuously identifies the causes and solutions to re-admissions”

2012 National State Hospital Average # of Readmissions = 7.4%

2008 WMHI Avg= 7.6%2009 WMHI Avg= 8.9%2010 WMHI Avg= 7.8%2011 WMHI Avg= 9.5%2012 WMHI Avg= 7.1%

7.4% Readmission Rate (October 2011-September 2012 Readmission Analysis Data)

*1506 Total Civil admissions ( 16% FY)

*111 readmissions

*44% Youth/56% Adult

*40% Male/60% Female

*58%Mood Disorders/18%Psychotic Disorders/9% DD

*Top 2 Reasons for Readmission

* 1) Aggression

* 2) Suicidality

Readmission Analysis: Implemented on all civil patients discharged and readmitted within 30

days

Our Process*Our Admission Coordinators screen each civil patient that is admitted

*The Admission Coordinator notifies the SW that this is a readmission.

*The SW completes the Readmission Analysis immediately.

*The SW, in collaboration with the patient and the county, completes the Crisis Plan prior to discharge.

*Copies of the Crisis Plan will go with the patient and the county upon discharge.

A Crisis Plan would be completed on all civil patients that were discharged and re-admitted

within 30 days.

*Continue to work with patients and county staff to develop crisis plans together.

*Gather data/determine if Crisis Plans are effective

*If Crisis Plans prove effective --Determine ways to expand their use

And along the way . . .

Learn from the Readmission Analysis Data/Crisis Plan to identify . . .

*Populations at risk

*Most effective aftercare resources

*Specific treatment to address crisis issues.