Ozaukee County NIATx 2018

1. Ozaukee CountyNIATx 2018 Ozaukee County Human Services Change Team Members: Heather Carlson, Laurie Rathke, Christina Johnson, Ashley Birkholz

2. Project Aim • Reduce re-admission to hospital (fewer costly hospitalizations) utilizing solid transition care support resulting in increased revenue from the additional contacts made by crisis staff. • Improve collaboration between providers during transitions in care. • Baseline: • No formal protocols regarding information between providers upon admission. • No formal discharge protocols regarding exchange of information between providers to ensure optimal transition of care. Reduce the rate of costly hospital re-admissions and increase revenue from additional crisis contacts

3. Change Project • Crisis staff will contact inpatient social worker and fax crisis note and/or police report to inpatient unit. • Crisis staff will contact inpatient social worker upon admission of voluntary patient after consent, and fax Release of Confidential Information. • Crisis staff will provide a follow-up call 3 days post discharge. • Crisis staff will request and log comprehensive discharge plan in agency electronic record. • Crisis staff will contact patient while inpatient to determine comfort level with discharge planning – (Abandon) Reduce the rate of costly hospital re-admissions and increase revenue from additional crisis contacts

4. Results 2017 ~ 9 re-hospitalizations within 5 month period 2018 ~ 1 re-hospitalization within 5 month period Reduce the rate of costly hospital re-admissions and increase revenue from additional crisis contacts

5. Lessons Learned • Sending crisis notes/police reports upon admission increased collaborative efforts with inpatient behavioral health units and improved communication. • One point of contact for consumer is better than multiple. • Reaching out 3 days after discharge gives consumer a chance to remember what it’s like to be independent of 24/7 providers. • Taking additional time both pre and post discharge with community partners, enhances client care, improves outcomes and reduces hospital re-admission. Reduce the rate of costly hospital re-admissions and increase revenue from additional crisis contacts

6. Next Steps • Adopted: Sending crisis note/police report upon admission helps assessment and increases collaboration between providers. • Adopted: Greater attention to all admissions (both voluntary and detentions) to maintain lower hospital re-admission rates. • Adopted: Follow-up call 3-days after discharge from inpatient hospitalization to check on mental health status, remind of follow-up appointments and inquiry about further resources as needed. • Adopted: New protocol for discharge paperwork and timeline to assist treatment staff with aftercare and follow up. • Plan: Research ways to engage voluntary admissions to better connect with resources. • Plan: Introduction of dashboard added to electronic record to enhance follow up procedures as a result of NIATx study. Reduce the rate of costly hospital re-admissions and increase revenue from additional crisis contacts