Critical Path Network

CMs take lead in discharge improvement initiatives

Project increases percentage of discharges by noon

At Ingham Regional Medical Center in Lansing, MI, case managers take the lead in a multidisciplinary effort to increase the number of patients who are discharged by noon.

"We make it clear that even though we are working as a multidisciplinary team, the case manager is ultimately responsible for running the show," says Dennis Perry, MD, MPH, director of case management and utilization review.

When the project was begun, the hospital's overall percentage of patients discharged by noon was 13.5%. In three months, the figure had climbed to 19%. It now has trickled back down to 17%, Perry says.

"The concept is out there and that's a good thing. We're working to overcome the barriers to an early discharge so we can increase the percentages," he adds.

Often, in the day-to-day work that takes place in the hospital, the treatment team loses sight of potential discharges, Perry says. Mornings are typically a busy time for the nursing staff and getting patients ready for discharge are not high priorities, he points out.

Case managers play a vital role in keeping the team focused on and working toward the goal of a speedy discharge for all patients, he adds. "Many times, a team gets interested in changing the way they do things but after a short period of time fall back into their old pattern. I want to make sure that doesn't happen in this case," he says.

At Ingham, case managers are assigned by floors and work with social workers who are assigned to multiple floors and handle discharge planning, utilization review, and communication with insurers. The hospital has patient care managers who act as nurse managers on each floor. They are not part of the case management department.

Patient care managers

"Getting the patient care managers on board has made a difference in improving discharges because the nurses report to them," Perry says.

Every day, case managers review the charts of all patients on their floor to get a sense of who might be a potential discharge for the next day. If they determine that it appears that a patient's goals have been met, they work with the admitting physician to ensure that everything will be in place so the patient can be discharged the next day.

They review the patients with the patient care manager and communicate with the staff nurse.

"We want to make sure that everyone is on the same page about which patients should be going home the next day. We give a heads-up to the attending physicians so we can get the orders in place and get all of the patient discharge needs taken care of ahead of time," Perry says.

The team works together to make sure the patients and family members are aware that discharges should take place by noon, and not 6 p.m. when the family member gets off at work, Perry says.

"We educate the patients from the get-go about why they are in the hospital and when they can expect to be discharged. We make sure that they understand that the case managers are working from Day 1 to take care of their discharge needs and to make going home as smooth as possible," he says.

The case management department recently has begun a morning report meeting with the case managers, the social workers, the home care coordinator, and other key players. During the 10-minute meeting, the case managers bring up the patients they anticipate will be ready for discharge the next day.

"The key players discuss the patients, how ready they are for discharge, and what they will need to be ready for discharge the next day. The meeting the next morning serves to remind the team of what has to happen to get the patient discharged," he says.

When the hospital began its discharge initiatives, two units piloted the effort.

"I was able to work closely with the case managers and patient care managers on those units and to have regular discussions to ensure that everything was working as it should and that the team was continuing to focus on a speedy discharge," Perry said.

When the team brainstormed to identify obstacles to a speedy discharge, they came up with three potential barriers — patient expectations, ancillary services, and physician cooperation.

"The case managers took care of the patient expectations pretty quickly. They give them notice of when they can expect to be discharged and tell them if they don't have a ride home, the hospital will get them a taxi. The case managers know how to say the right thing to prepare the patients for discharge," Perry says.

Initially, Perry sat down with the case managers and the patient care managers every week to discuss the discharge initiative. "That was difficult from a timing standpoint," Perry says.

Now the team discusses discharges and what holds them up in the regular case management meetings, he adds.

The hospital rolled out the system on two more units six weeks later, gradually involving every unit in the hospital. The first two units were 6 South, a medical floor with a large percentage of renal patients, and 5 North, a medical-surgical floor.

Early results positive

Before the project began, only an average of 12% of patients on 6 South and 13% of patients on 5 North were going home before noon. After the project began, the figures rose to 20% for 6 South and 18% for 5 North.

"It was very promising. We maintained the noon discharge percentages for three months," he says.

The next two floors that began the discharge initiative had a high volume of cardiac patients and heart catheterization patients. "These units already had a fairly high discharge rate but we were able to raise it from 20% to 25% within two months," he says.

Hitting a plateau

Then the team hit a barrier and the discharge rates stopped improving.

"The problem was, we were asking physicians to be everywhere at one time. We were working to get the discharges completed earlier in the day and they were overwhelmed and not able to effectively change what they were doing," Perry says.

At Ingham, a hospitalist group admits and cares for a large percentage of the medical patients. The hospitalists were short-staffed on physicians who make the rounds, and in many cases, the attending physicians had not been on the unit to discharge the patient in a timely manner.

The case management department has been looking at ways to overcome the barrier to a speedy discharge.

"We are anticipating a change in the way the hospitalist service works. There will be a significant increase in the number of physicians rounding on a daily basis," he says.

Under the new system, the case managers will guide the hospitalists as to who they should be seeing first and then ensure that the discharge summaries are complete.

The hospitalist group will dedicate several physicians to handling discharges.

"Our goal is to have 30% of the patients discharged before noon. Statistically, success in discharging patients early in the day is often dependent on the floor. There may be only eight patients waiting for discharge, but if they get four people out by noon, the discharge rate is 50%," Perry says.

Perry sees the discharge initiative as an ever-evolving process that is likely to have its ups and downs.

"We have learned that it is important to set a goal and come up with a plan to meet the goal, but that's not enough. You should always be looking at barriers and keep working toward the goal. It takes a lot of energy to keep a system going in any large organization, particularly when people are accustomed to doing things a certain way," he says.