Dry-erase board improves communication, discharge

Nurses, CMs write notes to each other

A simple communication tool used by case management and nursing has decreased the turnaround between when discharge orders are issued and the time the patient is out the door at North Broward Medical Center in Deerfield Beach, FL.

When case managers and nurses brainstormed about how to facilitate discharges, the group came up with the idea of using a dry-erase board that hangs in the case management office on each floor and has a space for the nurses and case managers to communicate about pending discharges, patient needs, and barriers to discharge, says Gavin V. Malcolm, LCSW, coordinator of social services at the hospital.

Simple tool makes big changes

The improved communication has decreased the time it takes to discharge patients to home by four hours and the turnaround time for patients being discharged to skilled nursing facilities by hour and a half.

"It's a simple tool. It doesn't add more paperwork or documentation but it facilitates communicating back and forth. It's made a huge difference in the turnaround time. When you're talking about Medicare length of stay, every hour counts," says Malcolm.

The board is divided into categories to facilitate communication. For instance, one column is for skilled nursing facilities discharges; another is for patients who will need home care and/or other services.

To protect patient confidentially and comply with the Health Insurance Portability and Accountability Act regulations, the case managers write the patient's room number, not the name on the communications board.

The case managers make the morning rounds with the charge nurse to talk about potential discharges. They make notes on the boards and update them as orders come in throughout the day.

Since each floor has different processes and different personnel, staff on each floor use the dry-erase board a little differently, Malcolm points out.

If the nurse tells the case manager during morning rounds that a patient is likely to be discharged to a skilled nursing facility the following day, the case manager enters the information on the board along with a to-do list, such as setting up an ambulance to transfer the patient or making sure the patient gets a physical therapy evaluation.

When the doctor comes in the next morning and writes the discharge orders, whoever is in the case management office knows what needs to be done and what has been done to get the patient ready.

"Even if the case manager who is in charge of this case isn't there, the rest of the staff know what needs to be done," Malcolm says.

If the nurse has a question or a concern and the case manager isn't in the office, she can just write the question on the board, Malcolm says. The nurses write the discharge orders on the board or call them into the case management department, rather than having to track down the case manager.

The nurses and case managers meet regularly for team building, an activity that has helped each discipline understand what the other does, as well as facilitating the best possible patient care.

"We have focused on reducing Medicare length of stay and how we can do it creatively while assuring that the patients are getting appropriate care," Malcolm says.

In the past, the nurses and case managers would leave notes for each other or leave voice mail messages.

"Sometimes things fell through the cracks. The notes got lost or people were too busy to check their voice mail. We were brainstorming on ways to eliminate this happening," he says.

Electronic discharge planning manual

Developing an electronic discharge planning manual that contains community resources and other venues of care also has been a tremendous help in facilitating discharges, Malcolm says.

"When we had our resources in a book, we had to change it every few weeks, print out more pages, and renumber them. Now it's on-line and we can make additions and deletions quickly and anyone in the hospital can access it if there is not a case manager in the hospital and a discharge is pending," he says.

North Broward Medical Center is a 409-bed hospital with a Level 2 trauma center, and is part of North Broward Health District, a four-hospital health care system.

At the medical center, case managers are unit-based. The hospital typically assigns two nurse case managers and one social worker to each floor.

Case managers work on weekdays from 8:30 a.m. to 5 p.m. and from 8:30 a.m. to 6 p.m. on Saturday. One nurse case manager or social worker stays until 8:30 p.m. to handle late discharges. The staff rotate being on call on Sundays.

The case managers are responsible for utilization review and discharge planning. The social workers focus on discharge planning for the more difficult cases as well as supporting the family throughout the hospital stay and helping them access community resources if needed.

The hospital's case management software is linked to the electronic medical record and is updated throughout the day.

The case managers enter a standard discharge plan for each patient into the case management software. The plan goes through all of the steps necessary for discharge and includes names and telephone numbers for family members or friends, medication issues, and other information. The plan includes the patient and family members' first, second, and third choices of post-discharge facilities, such as skilled nursing facilities, along with telephone numbers and names of people to contact.

"All of the case managers have access to the latest discharge plan and can easily see what steps need to be taken and determine any barriers to discharge. They can access the discharge plan remotely from anywhere in the hospital if it's after hours and they're on another floor," Malcolm says.

In addition, if a patient is being discharged when there is no case manager in the hospital, the staff can pull up the electronic medical record and know the steps they need to take for discharge, any issues or barriers, and contact numbers for the patient's family, he adds.

"We focus on discharges in the morning if possible, so if necessary, we can get patients transferred to another facility in time for them to settle in. If they're going home, we try to get them out of here so they can be there before dark," he says.

People who don't have a ride home and are able-bodied can take advantage of a free van service. The hospital also has a contract with a local taxi company to assist with transportation for patients.

"The case management staff on each floor send a representative to show that we are committed to the floor and this helps build relationships and a sense of working as a team," Malcolm says.

The case management representatives at the meeting provide feedback to the rest of the staff about customer service issues. For instance, if the patient complained that he was discharged too quickly or that the pending discharge wasn't communicated well, the representative takes it back to the team to discuss what could have been done better.