'Discharge by appointment' taking 'hard-wiring'

'Patients really like it,' director says

A "discharge by appointment" initiative at St. Joseph's Medical Center in Towson, MD, has had some success, but is being challenged by physician delays and families who aren't arriving on time.

"We're finding that some weeks are better than others," says Jackie Connor, RN, MS, CCS, director of case management. "We're working now to push up the number of patients scheduled. Our goal is 80% of the patients [in the project] will get a scheduled discharge date and time, but the most we've been able to achieve is about 50%."

Of those with scheduled dates and times of discharge, close to 80% were sent home on time, Connor notes. "We have to keep working with the physicians. The nursing staff is doing a great job, but many times, we are waiting for the physicians to arrive."

In addition, "the nursing staff is trying to be more proactive with patients and families," she says. "Another reason [for delays] is the family not getting here in a timely manner."

The idea was piloted in 2006 on the hospital's surgical unit and with interventional cardiology patients, and was expanded in early 2007 to include the patients of a large cardiology group and St. Joseph's hospitalists, Connor says. Initially, the project was to have expanded to all patients at that time, she adds.

"We decided just to expand on the cardiology unit, because to do it on seven units — with the follow-up and action planning — would have been very resource-intensive," Connor says.

It also was part of the original plan to identify a date and time of discharge within 24 hours of admission, she says, and there was a concern that the process would get confusing when the cardiology patients were transferred off that unit.

The project parameters were changed, Connor adds, when "we found that we were not successful in identifying candidates for successful discharge within 24 hours because the patient population was too complex."

"Patients came in and were here for a day or two or three being worked up," she explains. "We couldn't make a discharge plan when we didn't even have a primary diagnosis." Until that primary diagnosis and the treatment for it were determined, Connor says, "it was too difficult to determine the discharge date."

In view of that, the decision was made to schedule discharge the day before it occurs, she says. "Every day, the nursing staff and case managers do rounds and identify patients we believe are most likely to be discharged the next day."

The discharge is not actually scheduled until an agreement is reached with the physician, Connor says.

"Some of the processes are automated," she explains. "In order for the scheduled discharge appointment to be recognized by the physician and the ancillary departments, we have to communicate that time. Before the date and time can be put in to the system to alert the physicians and the ancillaries, there has to be agreement between the case manager or nurse and the physician."

Because the information is not entered until that agreement is made, Connor says, "if we see a date and time on the census reports that nurses use, the case management reports, or the physician roster, everybody can be assured" that the plan is set.

A small project team — made up of Connor, the nurse manager and case managers from the unit involved, a physician advisor, and one of the ancillary department managers — meets weekly to review data and decide what action steps to take, she says.

Ten weeks into the project, Connor adds, "we are happy with the results achieved. We believe we've accomplished what a lot of hospitals have not."

Follow-up telephone calls to those whose discharges were scheduled indicate that "patients really like it," she says. "They can plan, and look forward to [the discharge date]. It's all about the planning."

While the process "requires a lot of oversight and hard-wiring," the payoff is worth it, Connor says. "We've decided to continue our focus."

Effort began in 2005

The project has its roots in a discharge task force established in June 2005 as part of a three-year effort aimed at capacity maximization, explains Connor, who was hired in April 2005.

"We had an issue with 'boarders' in the emergency department, and as we started collecting data, what came to the surface was that if we could just fix transportation and discharge, 80% of the problem should be fixed."

One of the main goals set by the discharge task force was to increase the percentage of patients discharged by noon, she says, but even with that specific intent, several months of data collecting revealed little change.

"The concentrated effort toward getting everyone discharged by noon caused 'bolus' discharges," Connor adds, and then later in the day there would be "bolus" admissions. "There was not an even workload throughout the day."

That's when the decision was made to move to discharge by appointment, she notes.

(Editor's note: Jackie Connor can be reached at jackieconnor@catholichealth.net.)