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Get creative in dealing with long-stay patients
Tertiary care hospital frees beds for other acute cases
Through the efforts on an interdisciplinary team, the University of Wisconsin Hospitals and Clinics has been able to shrink the number of patients who remain in the hospital for 30 days or longer from an average of 60 or 70 in-house each day to an average of 20 or fewer.
As a tertiary care hospital, the University of Wisconsin Hospital receives patients that need specialized care from other hospitals all over the state. Many of the long-stay patients are trauma patients with complex head injuries or patients who have undergone transplants.
In the past, many of the patients have stayed at the University of Wisconsin Hospital for 30 days or longer even though they no longer needed specialty care, says Barbara Liegel, RN, MSN, director of coordinated care for University of Wisconsin Hospitals and Clinics in Madison.
Now, following a series of initiatives aimed at improving throughput, the hospital transfers many of the patients back to the referring facility after treatment or finds creative discharge solutions in the community.
"The level of acuity of the patients we treat is what turns many patients into a long-term stay patient; but keeping them for long lengths of stay impacts our capacity. It's not that we don't want these patients, but we have to open up beds so we can continue to serve patients with specialized needs," Liegel says.
A multidisciplinary team meets weekly to discuss patients with the potential for a long stay and looks for solutions. The team is chaired by case management and social work and includes representatives from admissions, the therapy staff, the legal department, physicians, palliative care, and the access center team, the hospital department that is accountable for admitting patients from referring hospitals.
"By participating on the committee, the access center staff learn what happens if a patient is not appropriate. Having them on the team makes them aware of the challenges with patients who are difficult to place," she says.
The team began by identifying the types of patients whose stays exceeded 30 days so that everyone in the organization would recognize the type of patients whose care needs to be managed, Liegel says.
At the recommendation of the team, the hospital updated all of the hospital transfer agreements with referring hospitals so that when the patient's tertiary care needs are completed, he or she is transferred back to the receiving hospital.
"Even on admission we talk to the transferring hospital and let them know that when we finish meeting the specialized needs of that patient, we are going to transfer them back," she says.
Holding referring hospitals accountable
In the past, many of the patients transferred for specialized care ended up staying at University of Wisconsin Hospital, Liegel says.
"We've done a fair amount of push-back. Some of the facilities don't want these patients back because they are hard to place. With the support of our senior management and the contracting team, we're holding our partners accountable for their patients. We tell the referring hospitals that we need to free up beds so that we will be here for them when they have a complex case," she says.
At the weekly meeting, the case management team gives a brief summary of each patient's status, including whether he or she still is meeting acute care criteria, and discusses the problems with discharge planning.
The entire team brainstorms to find solutions to the challenges the hospital faces in placing the patients. The team typically discusses patients who have been in the hospital 20 days or longer.
However, sometimes staff members may bring up patients with shorter stays who have the potential to become long-stay patients.
"Being in the hospital for days and days isn't the only solution. There are several kinds of alternative managed care home care situations in our city for young disabled patients and one for the elderly. They provide assistance with our creative care planning," Liegel says.
LTAC provides more discharge options
The opening of a new long-term acute care facility (LTAC) in Madison has given the hospital another option for discharge, she says.
"This has made it easier to discharge patients to an acute care facility that provides care and support for patients requiring prolonged hospitalization," she adds.
Before the facility opened earlier this year, the closest LTAC was more than an hour away, which put a burden on families whose loved ones were discharged there, she adds.
"We struggle with placement. The long-stay patients are quite complex. We have established a good relationship with the local nursing homes so we can help support patients who are appropriate at the nursing home level of care," she says.
The hospital often continues its support for complex patients after they have been discharged to a skilled nursing facility. "Once a patient goes to a skilled facility, we help problem solve and support the patient at that level of care. We are working with the skilled nursing facilities to elevate the level of care they can provide," she says.
The case managers often look for creative referrals for placement of some of the long-stay patients who no longer need an acute level of care.
"If the patient meets community care criteria, we have a case manager who works with the physician and nursing team to put a creative plan into place. A creative approach to discharge allows us to bring in a paying patient to fill the bed," she says.
For instance, a young woman from Illinois was transferred to the hospital after an automobile accident and needed to be on bed rest for six to seven weeks. She couldn't return home because she lived alone. She had no insurance. The hospital was able to place her in a group home and send out a home care agency to take care of her needs.
"She doesn't need an inpatient level of care and doesn't need a nursing home. Our choices were to leave her at the hospital for six weeks until she's ready to go to rehab or home or to look for a place in a less intensive setting," Liegel says.
The patient's workers' compensation company agreed to pay for her stay in the group home.
"Even if we don't get reimbursed for home care or durable medical equipment, it's more economical to pay for these patients to be in a less costly setting and open up the bed for paying patients who have acute care needs," she says.
The hospital's home care program has a home ventilator program that is an option for many patients on ventilators.
"If a patient has any chance of going home on a vent, we pull them into the program. We still need to set up home nursing and sometimes 24-hour nursing care is hard to find," she says.
Discharging to home
The team came up with a creative discharge plan for a long-term ventilator patient who was terminally ill. The woman wasn't competent to make health care decisions anymore, and her guardian didn't want to remove the vent in the hospital because she had promised the patient that she would make it possible for the woman to die at home.
"We sat around as a team and made the recommendation that we would arrange for transport home, support her at home, and disconnect the ventilator at home," Liegel says. Planning her discharge to home extended the patient's stay to well more than 30 days.
The committee arranged a family meeting and found a primary care physician in the community who was willing to go into the home. They arranged a home respiratory therapist and hospice care.
"It was a very creative solution to a unique situation," Liegel says.
The long-stay committee was developed as part of a far-reaching initiative aimed at improving throughput and increasing inpatient capacity. The average length of stay has dropped by more than a day since the initiative began in 2002.
Even with the more acute patients, the University of Wisconsin Hospital's average length of stay of 5.4 days compares favorably with a local community hospital with a length of stay just above four days.
"They have obstetrics, which typically means short-stay patients, and we do not," Liegel says.