MidCentral DHB: Reducing readmission rates amongst high-end users

Discovering that just 20 percent of their mental health and addiction (MHA) service consumers were using 80 percent of the allocated funds provided the impetus for a quality improvement project at MidCentral DHB.

Consumer Advisor and Project Manager Chris Hocken worked with Clinical Executive Dr Marcel Westerlund to define the problem. 'We sat in on multi-disciplinary team (MDT) meetings and it became apparent that our staff were typically siloed in their thinking. The main topic of conversation was often diagnosis and medication, rather than seeing the whole person. Our clinical team were working for their clients, but not with them.'

Chris and Marcel identified that clients didn’t understand how to access other services and were returning to MHA in-patient services for help that could have been given at a community level. 'A lack of awareness of community services meant we were creating learned helplessness.'

The team set a goal to reduce the number of readmissions of high-end service users (those with more than one readmission within 28 days of discharge), by 25 percent per annum.

To achieve this the team identified several process measures which put discharge planning at the forefront of patient care. 'We set an expectation that discharge planning was carried out at the very first interaction with a patient, and again prior to discharge. Every meeting was in essence a discharge meeting,' says Chris. The team also focused on improving the communication and connectedness of health and social services, 'We did a service mapping document and directory called Unison - together we flourish, whakapuawai tahi, which has gone to different teams.' They also now coordinate network group meet-ups once a month, 'This means we are all coming together – government, social and health services - as a region.'

The team established process measures for discharge planning, network group attendance and occurrence of meetings. They also looked at the discharge documentation, asking for consumer feedback on the design – 'they said it was too long and confusing'.

By March 2018, the team recorded a 90 percent completion rate in discharge planning, noted improved communication with consumers, and an increase in bed availability. According to Chris, the most notable outcome has been the increase in staff knowledge and connectedness across services and the increase in use of different agencies.

'For example, we identified that one lady had been admitted 85 times across different hospital services previously. Through this project we looked at her pattern of admission and found she always called at night. So, we worked with community agencies to change her home support so she is now visited at night time and the admissions have stopped. She had been lonely.'