Discharge Planning Advisor

'Basics' may be pushed aside in rush to trendier remedies

Patient throughput efforts could benefit from DP principles

Discharge planning starts at admission. It's one of the most basic tenets of the discipline, notes Jackie Birmingham, RN, MS, CMAC, but one that is increasingly brushed aside as hospitals focus on utilization review (UR) and bed management in an effort to enhance patient throughput.

As health care providers redesign emergency department (ED) processes and cancel elective surgeries in response to the capacity crisis, they often overlook the power of proactive and comprehensive discharge planning, says Birmingham, a veteran discharge planner who now is vice president of professional services for Curaspan Inc., The eDischarge Company.

"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.

"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."

The importance of patient choice is another principle that case managers should keep at the forefront of the discharge planning process, says Jackie Connor, RN, MS, CCS, director of case management at St. Joseph's Medical Center in Towson, MD.

"In the whole scheme of trying to facilitate discharges rapidly, this has the potential to be overlooked, she adds. "When you offer choice, give the patient options, it can slow the process down."

Nevertheless, Connor cautions, case managers should not only present available options to the patient but document that choices were offered.

"In a case where a physician wants the patient to go to a skilled nursing facility," she says, "the case manager or social worker may go in and say, 'I have a facility that can take you today, and I can get you all set up.' Certainly patients don't always know they have a choice."

More correctly, she adds, the patient should be told something like, "I have two, or three, or five facilities that have availability."

Medicare guidelines mandate that patients be given choices, not only Medicare patients but any patient, Connor emphasizes. "It's at the heart of the discharge planning process. It's required."

Be alert to 'red flags'

Including orientation, it takes about two years on the job before new case management staff are "fully functional," suggests Kate Tenney, RN, manager for case management at Sutter General Hospital in Sacramento, CA. That's the point, she adds, at which they "understand all the red flags that catch their attention, know the resources and how to move patients through the system."

Until about that time, Tenney says, "you can expect that they will miss things." She cites the recent case of a man in his 40s whose face sheet showed that he had Medicare coverage — a red flag that was missed by a novice case manager.

As a result, there was no initial assessment for discharge planning, and the patient — who had a disability, financial problems, and needed a post-acute placement — stayed in the hospital longer than he would have if the situation had been identified sooner, Tenney adds.

In many cases, she says, physicians don't mention those kinds of details, but just say something such as "a 47-year-old man admitted with a broken leg."

"Those little flags are what make or break an effective discharge plan," Tenney notes.

Such oversights can occur even with experienced case managers, points out Barbara Leach, RN, director of case management for Sacramento Yolo Sutter Health. They typically occur, she says, "when you're implementing a new software package or putting pressure on meeting criteria — anything that draws you away from doing the same procedure over and over again."

"You could be focusing so hard on InterQual that you get to a Medicare patient and say, 'I don't need to see this one,'" she says. "That's when [cases] fall through the cracks."

Seasoned case managers often have their own system and "bag of tricks" in place, adds Tenney, and are subject to overlooking things when a new methodology is introduced.

"For example, first I open the face sheet, then I look at the first order, then I look at the history and physical assessment," she says, describing her own routine. If management comes in with a new process for staff and says, "This is what you will do and how you will do it," Tenney continues, "it takes away their routine or tricks to identify potential patients that need additional discharge planning or social work."

That disruption can occur, for instance, when the department goes from a written methodology to a computerized one, she says. "You don't necessarily put all those little notes you write into the computer, and that's another opportunity to miss something."

Another frequent challenge to effective discharge planning has to do with knowledge of community resources, Tenney says. "These resources change over time, and we may not be kept abreast of what's available and what's not available."

"I was in a meeting a while back and someone mentioned a nurse who worked for a board-and-care facility," she recalls. "That is very unusual — typically [those facilities] just provide food and a place to live.

"This one not only provides a much higher level of care but has a nurse who works there and gets a higher level of reimbursement," Tenney notes. "We weren't aware that it even existed. Keeping up with what's available in the community is a big problem."

Typically, a case management nurse will put notes on this kind of information in her folder, Leach adds, and the person who covers for her won't necessarily have it. Similarly, she says, "when you transfer a patient from one service to another — say, from the intensive care unit to a med-surg unit — the bag of tricks with the thing that fits that patient might not be there."

Keeping case managers constantly informed of developments in the field — "growing" your staff — is another discharge planning basic that can fall between the cracks, Tenney says.

"With the kinds of caseloads they carry these days, there's not a lot of time to read literature or periodicals," she notes. "You need people in the organization who summarize what's available and send out tidbits to staff. That's missing in acute care, especially."

While it's hard to calculate the benefit and justify the cost of allocating staff for such a function, Tenney adds, there are ways to address the issue.

One is to look at ways to get staff talking with each other about cases so they're in a position to share their expertise, she says. "One of the things we've tried here is having a huddle with multiple staff — both experienced and inexperienced."

"When you watch them talk, you can see other case managers paying close attention to how someone solved an issue," Tenney continues. "You will see them writing down little notes. If you do it well, you have your senior case managers constantly mentoring new case managers without even thinking about it."

Leach says she holds a team meeting every week that includes case managers, nursing staff, and representatives from other disciplines. Attendees look at difficult cases and "hand off the easy wins from person to person. We've incorporated the ones for difficult patients," she notes, "so now the 'difficult' patients have to be 'very difficult' patients."

"There is a lot of learning that happens in that arena," Leach adds. "We've even brought in experts for, say, tuberculosis care in Sacramento County, and we've had the physician who is the head of health and welfare to talk about the expectation for acute care for patients."

Meetings where information is shared between case managers teaches them how to concisely describe a situation, the problems involved, and their recommendations, Tenney says.

Such gatherings work best if the sharing is kept brief and to the point, she adds. "If they get in the habit of doing that well, it teaches them to dialogue with physicians and nurses. It also allows for other people in the room to come up with ideas that might help them."

For more information, contact: Jackie Birmingham, RN, MS, CMAC, at jackiebirmingham@sbcglobal.net. Jackie Connor, RN, MS, CCS, can be reached at jackieconnor@chi-east.org. Kate Tenney, RN, can be reached at TenneyK@sutterhealth.org. Barbara Leach, RN, can be reached at LeachB@sutterhealth.org.