Health care leaders share discharge delay reasons

Lack of resources, communication cited

What is the No. 1 reason for patient discharge delays? Hospital Access Management posed that question to several leaders in the fields of access services and discharge planning. Their responses are below, along with some thoughts on how the problem can be addressed.

Beth Ingram, CHAM, director of patient business services at Touro Infirmary in New Orleans:

"The most common reason is not really a delay in the patient discharge, but a delay in notification of the discharge to bed control or in entry to the system," she answers. "The patient is actually gone, but the system hasn’t been updated, so those assigning rooms do not know the room is available.

"The primary reason we find is that the family doesn’t pick the patient up at the point of actual discharge. The reasons for this vary: The physician didn’t tell them in advance the patient was going to be discharged. They want to wait until after work to pick up the family member, and/or the patient wants to wait until after lunch/dinner to go. Another large contributor is that the physician wants to get the results of a test before the patient leaves, so he will write an order pending the lab test/procedure being performed.

"In the elderly population, we experience delays in getting appropriate arrangements for care after discharge. This issue can be reduced by having discharge planning begin at admission, or at preadmission for the major procedures that are known in advance."

Poor execution, bed turnover problems

Barbara Wegner, CHAM, regional director for access services at Portland, OR-based Providence Health System, says:

"I believe the root problem in discharge delays is a combination of poorly executed processes and problems that plague the bed turnover cycle. One of the major delays [could be alleviated by] getting the physician’s order to discharge earlier in the day.

"At the Providence Health System, we have a group focusing on triggering discharge earlier in the day, to include such things as physicians writing pending-discharge’ orders the night before to get the process started, flagging pharmacy, laboratory and diagnostic imaging orders to notify these services that the discharge is dependent on timely results, scheduling acute-care managers [discharge planners] to be available on the evening shifts to assist with discharge the following morning.

"In addition, support services must be available, such as ride-home’ shuttles, arrangements with long-term care facilities/foster homes to accommodate evening and weekend patient transfer, point-of-care testing in the ED [emergency department] and high-acuity units to facilitate timely completion of testing, decision-making triage, and disposition."

Poor written/verbal communication’

Kathleen Moreo, RN, Cm, CCM, CDMS, CEAC, co-owner of PRIME Inc. in Miramar, FL, says:

"I think the No. 1 barrier continues to be written/verbal communication. Discharge can’t occur because the doctor’s order isn’t in the chart; the written permission is not obtained; if the patient is going from one facility to another, the approval from the receiving physician hasn’t been received; or the approval from the payer hasn’t been received. From my training and consulting experience, this seems to occur more often than the fact that community resources don’t exist.

"Communication remains one of the most powerful tools — or barriers — to effective health care delivery. Delivery systems spend exorbitant time and funds on developing clinical guidelines and algorithms and revamping information systems while the fundamentals are often ignored. There is no doubt that one of the best tools in the discharge planner’s or case manager’s toolbox is skilled communication, coupled with effective relationships."

Sandra Lowery, RN, CRRN, CCM, president of CCMI Associates, in Francestown, NH, and immediate past president of the Case Management Society of America, answers:

"In my experience, psychosocial concerns are the No. 1 reason for serious delays. Under that category would be financing issues, decisions related to the environment they would be discharged to, and decisions related to the support services they would need, whether informal or formal. All of these pertain to the psychosocial needs of the individual more than the medical, although certainly both are affected."

Tina Davis, RN, MS, CMAC, senior director, continuum of care, Arnot Ogden Medical Center in Elmira, NY, says:

"The difficulty comes when there is an identified need and no resources to provide for it. It depends on the community you’re in and what services are available in the post-acute continuum. In our county, we have a shortage of nursing home beds, so the wait for transfer to a nursing home can be quite long. We also struggle with the Medicare prospective payment system because it becomes difficult to provide home care for those who need it when Medicare won’t cover, and these people very often don’t have the resources to pay for it on their own."

Adds Maria Hill, RN, MS, CMAC, senior consultant with the Center for Case Management in South Natick, MA:

"[The No. 1 reason] is lack of bed availability for Medicare/Medicaid-funded clients in a care facility in the patient’s community of residence."

Jackie Birmingham, RN, MS, managing director of professional services for Needham, MA-based Curaspan Inc., explains:

"Here are my top four reasons for delay in discharge from a continuum perspective:

  1. knowledge of bed availability in the post-acute setting;
  2. locating the appropriate facility for the patient in relation to payer, geography;
  3. communicating between hospital and post-acute intake;
  4. transferring medical information that can be used for post-acute care."

From Marne Bonomo, PhD, regional director for patient access at Aurora Health Care in Milwaukee:

"One of our bigger discharge issues is getting a ride home. We are currently evaluating transportation options, meals to home,’ and medication to home’ to help expedite emptying rooms sooner whenever the patient’s condition permits. On our new bed management eBoard, one of the indicators is patients with discharge orders,’ so that social services and utilization [management] can easily see where they need to direct their resources. Also, in addition to length-of-stay teams for each individual hospital, we have oversight length-of-stay teams for our regions. Reduction in length of stay is one of our key strategic goals."

Lisa Zerull, RN, MS, program director of Valley Health System in Winchester, VA, adds:

"The first thing to consider is the environment, whether it’s metropolitan or rural. With [our hospital] being rural, patients can live up to 200 miles away, so transportation is a big reason for discharge delays. We can discharge the patient at 9 a.m., but if the family can’t get here until 4 p.m., that person remains in our system. Another reason is physicians waiting until later in the day to discharge patients. We work in an environment where managed care has not penetrated the market, so there is no incentive for physicians to get patients out faster.

"Something that has greatly impacted our length of stay is that we now have a hospitalist on board, so we don’t have to wait for a busy family practitioner to make rounds [to discharge patients]. The trend is for family practice offices that are very busy to contract with a hospitalist to care for patients when they are hospitalized."