Need throughput solution? Try discharge planning

Remember the basics, veteran CM says

As hospitals struggle to improve patient throughput by streamlining their emergency departments and installing bed management software, they often discount one of the most basic tools at their disposal, says Jackie Birmingham, RN, MS, CMAC, a veteran case manager and discharge planner, who is now vice president, professional services for Curaspan Inc.

As health care providers focus on utilization review (UR) and cancel elective surgeries in response to the capacity crisis, they overlook the power of proactive and comprehensive discharge planning, adds Birmingham.

"Whenever I hear [providers] talking about patient throughput, they sort of [add] 'and, oh, discharge planning,'" she says. "When I listen to patient throughput scenarios, there is talk about bed management tools and ED fast track, and what's happening is that the case manager is spending a lot of time doing UR and not enough time counseling on the patient's readiness for discharge."

Birmingham says she recently came across a situation in which a patient was in the hospital for 10 days, but not until the morning of discharge did staff begin to go over diet and medication issues. At that point, she adds, the family learned for the first time that the patient — who was being treated by several specialists, including a cardiologist and a pulmonologist — had developed prednisone-induced diabetes during the stay and was on insulin.

"I think that the case manager was very involved with getting approval for the nursing home stay and tracking continued stay [criteria]," Birmingham says, "but when it came to the simple discharge plan, that kind of got shunted off."

If UR staff are thinking that a patient is getting close to the end of what will be considered an appropriate hospital stay, she advises, the discharge planner should be actively involved in the process.

"This [concept] is so old — discharge planning rules were proposed in 1986 and passed in 1988," Birmingham says. "But now the admitting staff are looking at what beds are available and predicting how long the patient should be there so they can book the next surgery, and the case manager is looking at the clinical processes that justify the continued stay.

"When it comes time to discharge the patient," she adds, "it seems to be a surprise."

There is a mindset among many patients admitted to the hospital, Birmingham suggests, that they are not going to leave until they are totally independent.

"They don't understand that acute care is a very short part of their episode of care, so they want to stay longer," she says. "It's not all patients, but it's the elderly person with a cardiac condition, who has a child [providing care] who might also be elderly with a cardiac condition.

"The fact that patients come into the hospital and are not the way they were before and probably never will be is kind of a shock to the family," Birmingham adds. "The family still pictures the hospital as where you go and get better, but it is where you go and get stabilized. [The patient] is like, 'I'm not well enough to go home, but I don't want to go to a nursing home.'"

Meanwhile, she says, the family is not brought up to speed on short-term nursing homes or home health or adult day care.

Discharge planning and patient throughput

"In the tweaking of patient throughput," Birmingham continues, "they're not putting enough emphasis on discharge planning. It was intended to move patients. Some people look at discharge planning as writing a plan and being done with it."

She recalls talking to a group of engineers who posed the question, "If discharge planning starts on admission, why does it take so long to discharge a patient?"

What is lost sight of, Birmingham says, is that "discharge planning" is an active term. "It's planning, not a plan. It's assessing a patient: If you're going home, well, what do you need to go home? Do you need to see a physician? Do you need equipment? Do you need medications? Do you need to be taught how to test blood sugar?"

Without proper attention to those questions and others, she says, within a short time "the family is clamoring for information, calling the physician back — and the readmission rate from home health care is almost 40%.

"Patients going to a nursing home get a lot more scrutiny than those going to home health care," Birmingham adds. "I'm putting the blame on discharge planners. They may think home care is fairly routine, but it's really risky [for patients] going to an environment where there is not 24-hour care."

A discharge plan is more like a video than a snapshot, she notes. "It's a moving reel, and then you take a snapshot at the end.

"It can be done along with other tasks, and fits quite nicely with case management, utilization review, and clinical pathways," Birmingham says. "Capacity management is so important now that a little more emphasis is needed on how you do discharge planning."

(Editor's note: Jackie Birmingham can be reached at