Acute inpatient post-discharge community care

Acute inpatient post-discharge community care, more commonly referred to as 7-day follow-up or KPI 19, measures the percentage of acute inpatient discharges that are followed up in the community within the 7 days immediately following discharge. A responsive community support system for persons who have experienced an acute psychiatric episode requiring hospitalisation is essential to maintain clinical and functional stability and to minimise the need for hospital readmission. Service users leaving hospital after a psychiatric admission with a formal discharge plan, involving linkages with community services and supports, are less likely to need early readmission. Research indicates that service users have increased vulnerability immediately following discharge, including higher risk for suicide.

Data available through January 2023, sourced from the 22 February 2023 refresh of the PRIMHD DataMart.

Please note:

  • Waikato DHB data is incomplete after November 2021
  • Bay of Plenty DHB has low volumes for contact from Oct 2021
  • Tairāwhiti DHB has no referral ends for inpatient from March 2022

Data visualisations

National quarterly summary

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Individual DHB summaries

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MOH quarterly reporting

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Heat map comparison matrices

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Explore trees

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National quarterly summary

This report provides a national overview of 7-day follow-up rate within a single financial quarter. It includes changes in national 7-day follow-up rate through time, as well as the follow-up rates for each DHB compared against the national average.

Within individual DHBs, the 7-day follow-up rate can be compared against either the previous quarter or the same quarter in the previous year.

The entire report can be filtered by financial quarter and team target population, as well as key demographics: age, gender and prioritised ethnicity.

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Individual DHB summaries

This report provides individual DHB summaries, by either financial year or quarter. 7-day follow-up rates are split by age, gender and prioritised ethnicity, and raw data is provided for crosscheck in your local system.

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MOH quarterly reporting

This report provides numbers for the DHB performance measure, Improving mental wellbeing MH07: Improving mental health services by improving inpatient post discharge follow-up rates, in a format that can be easily copied into the reporting template. Raw data is provided for crosscheck in your local system.

Summary tables allow comparison between DHBs for total population or ethnicity splits, and bar charts show each DHB tracking against the national average.

Date selections are fixed to the official MOH periods for this measure, a rolling 12-month period reported 3 months in arrears.

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Heat map comparison matrices

This report provides heat map matrices that compare 7-day follow-up rate per DHB, split by either age, ethnicity or gender. To account for the small sample sizes encountered when splitting data into more granular groups, the user can specify thresholds to highlight only intersections with a sufficient number of referrals and high follow-up rate; for example, any age group at a DHB where at least 50 acute inpatient referrals were discharged and the 7-day follow-up rate was over 90%. This makes it easy to find stellar performance to investigate.

An additional suite of heat map matrices compare the change in 7-day follow-up rate since the previous year, also split by age, ethnicity or gender. Here, the user can highlight intersections where the magnitude of change exceeds a specified threshold; for example, any ethnicity group at a DHB where there were at least 35 referrals both last year and this year, and where the 7-day follow-up rate has changed by at least 10% since last year. This makes it easy to find areas where performance has been improving or deteriorating, for discussion or further exploration.

The entire report can be filtered by financial year and target team population.

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Explore trees

This report is shared with 28-day readmission.

Explore trees allow you to drill down through the 7-day follow-up data in any order you like, exploring and comparing different cohorts and time periods. This report includes both a simple and advanced trees, as well as several examples with explanation and discussion. This report also incorporates 28-day readmission data, so you can switch between the KPI rates or explore counts of referrals both followed up and readmitted.

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Ask me anything

This report is shared with 28-day readmission.

This is a natural language processor – type in a question or something you want to see, and the data will answer.

Both the 7-day follow-up and 28-day readmission datasets are available to this tool, so you can explore the relationships between these two acute inpatient KPIs. Every question you ask helps it to learn and if you have time, you can leave feedback about how it answers each of your individual questions.

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