Waukesha County DHHS Clinical Services Division

Project Aims

• Reduce the number of patients readmitted within 30 days of hospital discharge.

2009 readmission rate was 9.45% • Increase the percentage of first outpatient

appointments kept.2009 rates:

₀75% of therapist appointments₀70% of psychiatrist appointments

ChangesStreamlined discharge teaching:• Patients receive a one sheet summary of discharge information.

Formalized day of discharge “check outs”:• Patients meet with their social worker and nurse to review

appointments, crisis plan, community resources and medications.

Follow-up phone calls within 3 days of discharge by crisis worker: • Review discharge information• Identify and eliminate barriers to successful transition to

outpatient services• Provide crisis intervention if needed

Results30 Day Readmissions

0

2

4

6

8

10

12

14

1 2 3 4 5 6 7 8 9 10 11 12 13

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Four Week Time Periods

2009

2010ba

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Results First Outpatient Appointment Kept

Next Steps/ImpactSustain process improvement.• Adopt discharge instruction sheet and “check

outs”. The changes simplify and organize discharge instructions and reinforce the importance of post-hospital care.

Shift focus from global process improvement to an

individual case-based review.• Case-by-case review of reasons for readmission

with patients readmitted within 30 days of discharge.