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Shawano County

This project aims to reduce 90-day readmissions, improve crisis case management, and increase referrals to Community Mental Health services. By increasing face-to-face contacts post-discharge, enhancing case management efforts, and collaborating with CMH, we aim to decrease readmissions and support high-needs consumers. The project has shown progress in reducing readmits due to non-compliance and increasing crisis referrals. Through adaptation and intensive follow-up services, we strive to further enhance support for consumers. The cost impact has been significant with decreased inpatient fees. Join us in this collaborative effort to better support mental health consumers.

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Shawano County

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  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 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 • 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

  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 • 2016- 489 • 2017- 523 • 2018 (1/1-10/1) -433 • Diversion numbers- • 2016- 58 days • 2017- 135 days • 2018- 370 days and counting • Cost impact- IP fees decrease as CMH consumers have MA

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