Wellstone Regional Hospital serves multiple counties in Indiana and Kentucky and is part of the Universal Health Services (UHS) system which is the largest inpatient psychiatric hospital system in the United States. Since 2015, dozens of hospitals across the UHS system have implemented Zero Suicide. In 2017, Wellstone incorporated new practices, based on the Zero Suicide model, building on existing performance improvement efforts that included a post-discharge wellness check protocol designed to address readmissions.
Key Outcomes:
- There was an overall trend toward lower numbers of readmissions at 30-, 60-, and 90-days after discharge in the year after Zero Suicide implementation compared to the year before.
- 90-day readmissions decreased 11% during 2017, compared to a 2% decrease in 2016.
About Wellstone Regional Hospital
Wellstone Regional Hospital offers both mental health and chemical dependency programs for inpatient, Intensive Outpatient Programs (IOP) and Partial Hospitalization Programs (PHP) for geriatrics, adults, children, and adolescents. Wellstone Regional Hospital is licensed for 100 acute beds with a breakdown of 24 geriatric, 12 transition, 14 adult psychiatric, 10 adult CD/rehab, 20 child, and 20 adolescent. The facility primarily serves the Clark, Floyd, Scott, Washington, and Harrison counties in Indiana and the outlying Indiana counties. We are located on the border of Louisville, Kentucky. Wellstone serves the Louisville Metro Statistical area, which includes multiple counties.
Wellstone Regional Hospital offers assessments 24-hours a day, seven days a week to all individuals and provides mobile evaluations to local schools, courts, and health care providers. We provide tele-assessments and mobile assessments to multiple agencies, providers, and facilities. The hospital offers a full-range of specialized psychiatric and addiction services for children, adolescents, adults, and seniors. Wellstone is known for geriatric psychiatry, with a specialty in Alzheimer’s and dementia stabilization care. All Wellstone Regional Hospital’s psycho-education and psychotherapy services are built on evidence-based practices. In addition to these services, Wellstone provides horticulture therapy and music therapy as part of our specialized therapies program.
Setting the Stage for Zero Suicide Implementation
At Wellstone Regional Hospital, our story is an ever-evolving quest to meet consumer needs and ensure that those struggling with mental illness have access to the treatment they need. In approximately 2011, using Performance Improvement data, our leadership team identified a trend of readmissions. These readmissions were post-30-day, 60-day, and 90-day acute treatment. This was consistent across the board for all age populations receiving services at Wellstone. As we explored this data further, we found that access to mental health services post-discharge were not always timely and that consumers did not always attend their follow-up appointments. Access to services post-discharge was problematic for Wellstone consumers. We collaborated with community providers, but they were strapped for resources due to a growing consumer population. While this lack of resources was identified as a contributing factor for frequent readmissions, we decided to focus our efforts on the area within our control: helping to make sure our consumers had a plan in place to get to their aftercare appointments. In 2011, Wellstone’s clinical director implemented a post-discharge wellness check protocol. The protocol stated that all consumers would be contacted within 72 hours of discharge. In addition, three documented attempts would be made to reach the consumer within the 72 hours. Since this would be quite an undertaking, initially the clinical director took on the task of making all the wellness check calls. In order to do so, however, a call sheet was developed that focused on key factors for success post-discharge that would only take minutes to complete.
- How have you been doing since discharge?
- We want to re mind you that you have a follow-up appointment with___________on date/time. Will you be able to keep this appointment?
- Do you have any immediate concerns for your health or safety that cannot wait until your aftercare appointment?
- Have you been able to obtain your prescriptions if the physician prescribed medications?
We collect data on the completion of wellness check phone calls and place the completed call log document in the consumers’ closed charts. These post-discharge wellness checks have been a positive thing for the facility and have saved lives. For example, we’ve reached consumers who were at risk for suicide after a recent discharge. We were able to provide invaluable treatment and save a life. Wellness checks have also allowed our staff a chance to activate social service and police wellness checks if a consumer sounds like they may be at risk when they are called, or if they fail to answer the phone. We ensure that prior authorizations for medications have been completed when necessary, and we have a chance to remind consumers about follow-up appointments they may have missed if not reminded. We are proud that our post-discharge wellness checks began in 2011 and are still being done to date. Eventually, we included other staff members in the post-discharge wellness checks. However, the clinical director maintains oversight of this important initiative.
Implementing the Zero Suicide Framework
In 2017, we decided that we wanted to build off the success of our post-discharge wellness calls and make a commitment to safer suicide care in our whole system by implementing the Zero Suicide framework.
We did the following:
- Zero Suicide Organizational Self-Study
- Zero Suicide Virtual Academy, Community of Practice (CoP), and Virtual Showcase
- Assessing and Managing Suicide Risk (AMSR) training
- Improved discharge planning process
Zero Suicide Organizational Self-Study
The first Zero Suicide Organizational Self-Study was taken when we started the Zero Suicide Virtual Academy. All leadership team members participated in the completion of the Zero Suicide Self-Study, and in July 2018, we completed the Zero Suicide Organizational Self-Study again to track implementation progress made one year post-completion of Zero Suicide Academy and AMSR implementation.
Zero Suicide Virtual Events
Our parent company, Universal Health Services Inc. (UHS), provided us with an opportunity to learn from our peers by participating in a Zero Suicide Virtual Academy developed by the Education Development Center for UHS. The Zero Suicide Virtual Academy combines an online learning platform and virtual meetings to create a learning experience for UHS inpatient hospitals launching Zero Suicide initiatives. As of the publication date, over 35 UHS facilities have participated in the Zero Suicide Virtual Academy. It was important to us that leadership staff participate in the Virtual Academy so that they would champion the initiative and foster buy-in from the staff members they oversee. Key leadership members included the clinical director, director of nursing, risk manager, performance improvement director, emergency services director, utilization management director, outpatient services director, and the CEO. The meetings allowed peers from other UHS facilities to share openly about their Zero Suicide implementation efforts, triumphs, and challenges. Through this interactive dialog we were able to share best practices and adapt polices from other facilities to make them work for Wellstone as well. Our leadership team felt inspired by listening to the stories of other people and set those ideas into motion.
Our data supports that implementing the safer suicide care components of the Zero Suicide framework (e.g., improved discharge planning and training our staff in suicide risk assessment), in combination with our wellness call efforts that we began prior to implementing Zero Suicide, has led to fewer readmissions.
Assessing and Managing Suicide Risk (AMSR) Training
To continue improving care for our patients, Wellstone created a facility-wide training plan for clinicians and mental health technicians to attend an AMSR training. The CEO even completed the AMSR training in an effort to foster buy-in from staff members. Wellstone has two AMSR trainers on staff: the director of nursing and the clinical director. Together, they provide a thorough AMSR training, with booster sessions approximately every quarter. Following the implementation of this new training plan, we have seen improvements in documentation clarity as well as family and support group inclusion during discharge planning. Implementation of Zero Suicide at Wellstone is guided by the AMSR training as reflected by revising initial and ongoing risk assessment processes, enhancing communications between teams, and increasing involvement from the patient’s support system.
Improved Discharge Planning
The Zero Suicide Virtual Academy meetings focused on the “transition” element inspired us to make some improvements in our discharge planning processes. A concentrated effort was placed on safety planning and family or support person inclusion. In fact, we viewed this as so important that we created a specific admission/discharge room and hired staff to ensure the discharge process was thorough and no patient left without a completed and reviewed safety plan. In addition, all attempts are made to review the patient’s safety plan with a support person and have them also sign safety plan documents.
Results
Comparing readmissions data from before and after Zero Suicide implementation, we have seen promising results. For example, 90-day readmissions decreased 11% from 2017 to 2018, compared to a 2% decrease from 2016 to 2017.
The following table shows the readmissions in the year prior to Zero Suicide implementation (5/1/16–5/1/17).
| Days after discharge | Number of readmissions | % decrease from previous year |
|---|---|---|
| 30 | 318 | 1% |
| 60 | 463 | 1% |
| 90 | 552 | 2% |
This table shows the readmissions in the year after Zero Suicide implementation (5/1/17–5/1/18).
| Days after discharge | Number of readmissions | % decrease from previous year |
|---|---|---|
| 30 | 293 | 8% |
| 60 | 411 | 11% |
| 90 | 492 | 11% |
Our data supports that implementing the safer suicide care components of the Zero Suicide framework (e.g., improved discharge planning and training our staff in suicide risk assessment), in combination with our wellness call efforts that we began prior to implementing Zero Suicide, has led to fewer readmissions.
Future Plans
Health care is about evolving to meet the changing needs of consumers. Our discharge room is continually being modified, and as we encounter issues with it, we meet as a team, create an action plan, and put that plan into action. When we completed the Zero Suicide Organizational Self-Study again after a year, we discovered that we lost sight of some areas we had identified as growth opportunities as efforts were put into other areas. As a result, we are hoping to continue building momentum to continue with Zero Suicide implementation goals and improvements. Incorporating voices of lived experience in Zero Suicide implementation is a key tenet of the Zero Suicide framework, so one area that we are prioritizing for the next year is engaging with individuals with lived experience as a way to ensure that our consumers are receiving the best care. Additionally, we will continue to offer staff support through the AMSR training booster sessions.
Authorship Details
- Gregory Stewart, LMHC, LCAC, LPCC, Chief Executive Officer
For more information contact Gregory Stewart at greg.stewart@uhsinc.com.