NIATx project yield big changes in Kenosha County

"Engaging in the NIATx process has had many great outcomes for us," says Kari Foss, Crisis Stabilization Unit Coordinator at Kenosha Human Development Services in Kenosha, Wisconsin. 

Those outcomes include a new process for responding to crisis calls, a stronger relationship with local law enforcement and other community stakeholders, and funding to support an additional full-time staff position.

Kenosha Human Development Services (KDHS) is one of 10 Wisconsin behavioral health agencies from 12 counties that participated in the latest round of the NIATx Wisconsin Mental Health Collaborative. The Wisconsin Department of Mental Health and Substance Abuse Services funds the project. The goal of the collaborative is to reduce 30-day readmissions to psychiatric hospitals.

Foss and other participants shared the results of their NIATx change projects in an October 2016 at a wrap-up session held at the Wisconsin Dells.

KDHS is a non-profit agency that is certified by the state of Wisconsin to provide crisis services 24-hours a day, seven days a week.  State regulations define crisis as “any situation caused by an apparent mental disorder causing a high level of stress or anxiety that can’t be alleviated by an individual’s coping methods.” 

 "The callers decide if they’re in a crisis, and we respond to every call," explains Foss. "Calls are often the result of stress or anxiety due to a financial crisis, relationship problems, homelessness, an alcohol or drug problem, or issues related to more serious and persistent mental illness." 

Foss adds that with every crisis call, KDHS works with county law enforcement on decisions about a patient’s emergency detention to one of the state’s two psychiatric hospitals.

Start with the “who?”

One of the first things that Foss and her team wanted to do as part of their NIATX project was identify which KDHS clients were being referred for psychiatric hospitalization. A review of data from January through June 2016 showed that 34% of those referred to Winnebago Mental Health Institute (the closest facility) had three or fewer contacts with KDHS.

"These were clients that we had never served through any of our other programs," says Foss. "That steered us toward looking at identifying our target population and how we do our assessments.”

The flowchart “aha!” moment

With 20 years of experience, Foss thought she knew KDHS workflow and processes pretty well. That is, until NIATx coach Betta Owens had Kari and her team do a flowcharting exercise to help figure out what their system was like for a client who had little or no previous contact with KDHS. 

“A lot of little things came together as a result of the flow chart exercise, and that led to some major changes,” says Foss.

For one thing, the flowcharting exercise showed that the system works well for people who are already in the KDHS data system. That led to a search for an objective tool that KDHS staff could use for standardizing the assessment process. They selected the Columbia Suicide Severity Rating Scale, which is widely used by other crisis programs across the state and nationwide.

A second “aha!” moment resulted when the team also realized their mobile staff lacked mobile access to the client data and tracking system. The solution was to give mobile workers iPads preloaded with the client tracking system.  The iPads also include with the CSSR scale so the mobile staff can use it to identify a person's suicide risk.

Local law enforcement

"Local law enforcement is called in for all of our emergency detentions, so we realized we had to them involved in our change project," says Foss. County police are responsible for transporting patients referred for psychiatric admission.

Foss and her team organized a presentation for Kenosha County law enforcement, sharing what their data on emergency detentions had uncovered: Of the 343 patients referred for hospitalization from January to June 2016, only 128 (about 37%) went on to court for an involuntary commitment or medication order.

The remaining patients had to be dismissed from the facility within the first 72 hours of arrival—meaning that law enforcement personnel were sometimes tied up in an emergency for an 8-hour shift or longer to transport the client to and from the facility.

"Our law enforcement representatives were shocked when we showed them this data," says Foss. "But this is where we got started on making our measurable change."

Bringing the community together to divert crisis calls

With law enforcement on board, Foss and her team set a goal: to divert ten mental health assessments from the ER to the main KDHS office in two months. 

 "We thought that if we could divert just ten individuals in the next two months, we could make an impact regarding cost savings to the county," says Foss. "Hospital costs alone are $1200/day, and that doesn’t include transportation costs.”  

This change began with sending a memo to local law enforcement explaining exactly what KDHS wanted to do and why. And then, Foss and two crisis workers attended 45 different roll calls.

“We stood in front of every single patrol officer and explained why this change was important,” says Foss. “We stressed the need to meet people’s needs in our community before sending them outside for services they might not need."

Foss adds that it was important to have the support of a law enforcement administrator to secure buy-in for the proposed change in protocol. "The support we received from those administrators was critical," she says.

The standard protocol had been police to take a client in crisis to the local ER, and then call a KDHS staff person to meet them there to complete the mental health assessment.

As part of the new initiative, a KDHS crisis staff member meets the law enforcement officer wherever a crisis might be happening.

“That ranged from meeting the officer at a busy intersection on Highway 13, to a park bench, to an individual’s home,” says Foss.  “If the person was stabilized and did not have an emergent medical need, the police officer brings the patient to the KDHS office where a crisis center staff person completes the assessment. What we can provide at our office is sometimes incredibly helpful for someone who is in a situational mental health crisis," says Foss.

Results

The new approach began on September 1, 2016. By early October, Foss and her team had exceeded their goal by diverting 38 assessments from hospitalization. By the end of October 2016, that number had increased to 52.

"The results surpassed my expectations," says Foss. “We were able to show the county board that this using the NIATx approach was so effective that they gave us funding for another full-time crisis staff person who will provide outreach in tandem with law enforcement in our community.”