CSP Case Management and 1 more...less...

How Well Did We Do It- CSP

CSP: % Clients Seen Within 30 Days of Discharge From the Hospital, by Fiscal Year

95%FY 2017

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Story Behind the Curve

Written By: Leslee Tocci

Updated: September 18, 2018

The blue line represents the percent of all CSP clients who have engaged with a service provider at WCMHS, within 30 days of discharging from a psychiatric hospitalization.

The above data shows a consistent trend, with a range between 95-100% since FY2009.

 

Partners

Successful discharges from psychiatric hospitalizations, depend on collaboration with staff at each of the area hospitals and The Department of Mental Health. In addition, depending on the needs of individuals, connection with WCMHS might depend on collaboration with other organizations and service providers (i.e., primary care physicians, Central Vermont Home Health and Hospice, community care homes, psychotherapists, etc.), as well as with the clients and their non-professional supports (i.e, friends, family, etc).

What Works

On average over the last eight, more than 98% of CSP clients have engaged in services at Washington County Mental Health within 30 days of being discharged from a psychiatric hospitalization. The majority of clients we serve through CSP (more than 80%) participate in our services voluntarily, and can chose to have contact or disengage after discharge from a psychiatric unit, but most choose to engage with services. Very few clients enrolled in CSP refuse contact after a hospitalization, or wait more than 30 days to make contact. In fact, last year, 100% of CSP clients had contact with a service provider within 30 days of discharging from a psychiatric hospitalization.

While most clients are wanting contact with staff throughout their hospital stay, and following their discharge, some choose to go though this experience without support from WCMHS providers. Those clients may leave psychiatric hospitalizations against medical advice; discharge to nursing homes or assisted living facilities out of county; transfer to medical units where they pass away, or seek services elsewhere (possibly because involuntary hospitalization damaged the therapeutic alliance). As the numbers reflect, most individuals who receive services in the Community Support Program, are wanting to have continued contact with staff at WCMHS.

Whenever possible, case managers are working with clients and hospital staff throughout the hospital stay to plan for a successful discharge back to the community. In some cases this means a case manager will be having ongoing meetings with a client and hospital staff, and on the day of discharge will pick up the client to bring them home, stopping at the pharmacy to fill prescriptions and at the grocery to get food, before settling them into their home, and scheduling a follow-up appointment. In other cases clients may prefer to go through the discharge process with friends or family, or on their own. After being surrounded by health professionals and patients around the clock at the hospital, some clients prefer to discharge home and take some space to themselves before jumping right back into treatment. In these cases, the time they take to connect with providers is usually only a few days. Over the past seven years, contact with clients has happened within 24 hours of discharge from a psychiatric hospitalization, 74% of the time; and within one week of discharge 95% of the time. Whenever possible staff are maintaining a connection with clients throughout the hospitalization, discharge, and period following hospitalization. Ultimately, clients decide when their first contact will be with staff, post discharge. What works best is to offer support and assistance and then to respect the clients personal choice and boundaries.



Action Plan
  • Focus on staff retention to ensure manageable case loads, which will ultimately result in availability for the highest level of support to program participants post hospitalization and throughout their treatment.
  • Work on prevention strategies (alternatives to hospitalization, good engagement and supports to avoid crises, etc.) to reduce psychiatric hospitalizations.
  • Improve collaboration with area hospitals, so that WCMHS staff can more fully participate on the day of discharge.

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy