Approach increases reimbursement, cuts LOS

ED social workers help avoid social admissions

A multipronged approach has helped the University of Iowa Hospitals and Clinics find funding for indigent patients, cut the length of stay for patients who are medically able to be discharged, and reduced the number of nonemergent visits to the emergency department (ED).

Many of the homeless and indigent patients in Iowa City are treated at the University of Iowa Hospitals and Clinics. Many of those patients present with barriers to discharge and complicated social needs, says Greg Jensen, ACSW, LISW, director of social services.

Social workers assigned to the ED help avoid admissions of patients who do not meet acute care requirements and provide case management services for patients who use the ED for primary care. Other dedicated social staff help indigent patients fill out applications for Medicaid, disability, and medication assistance.

When patients are ready for discharge but remain in the hospital because they don't have a way to pay for the equipment, supplies, or medication they may need, discharge planning staff can tap into the hospital's expedited discharge fund, which can be used to get the patient what he or she needs to be discharged.

"If a patient is medically ready to leave, the social workers can start the application process to use the fund to transport patients to home, provide antibiotics or equipment. This has been helpful in shortening our length of stay," Jensen says.

A multidisciplinary team conducts weekly review rounds for any patient who has had a length of stay of more than four days. The unit social workers provide a status report. A physician is available for consultation and to talk with the treating physician if there are medical issues. In a typical week, 250-280 patients are reviewed.

"We look at whether there is something we might do from an administrative, social, or medical perspective to assist with getting them discharged," Jensen says.

"This process raises the attention of the treating physician and the social workers on the unit to see if these patients can be moved through the continuum more efficiently and timely," he says.

Social workers staff the ED from 10:30 a.m. to 11 p.m., seven days a week, working with the ED staff to find a place for patients who don't require acute care. In just six months, the social workers averted admissions of 46 patients who would have been admitted for social reasons.

Some of those patients were elderly people whose family was having trouble caring from them at home.

"The social worker conducts crisis intervention with the family. They look at getting respite care or home health arranged for the families so they have support," Jensen says.

University of Iowa Hospital is the only teaching hospital in the state and often receives patients from other facilities and nursing homes. Sometimes these patients don't meet acute care admissions criteria, but by the time the ED staff determine it, the ambulance has driven away.

In those cases, the social worker calls the referring facility and uses the expedited discharge fund to pay for an ambulance to take the patient back.

"Before we had a social worker on-site, the emergency department would admit patients and let somebody know about it the next day," he says.

By providing case management services for patients who use the ED as a primary care provider, the ED social work staff have been able to reduce visits by nonemergent patients by 59%.

"Coming to the emergency department for treatment is not the most efficient or coordinated way to get care. The patients are not likely to have the same doctor every time, and the clinicians respond only to what brought them in that night," Jensen says.

When the program began, the emergency department staff compiled a list of patients who came in frequently and who could better be cared for by a primary care physician, Jensen says.

When one of the patients on that list comes into the ED, a social worker meets with them, assesses their needs, and finds out why they are using the emergency department frequently. They develop a plan to help the patient connect with community-based resources, such as substance abuse programs, and to find a primary care physician.

"Many of these patients are near-indigent. Some are drug seeking or have behavioral of psychiatric issues at play. Others are victims of domestic violence. They typically have complex psychosocial needs, as well as medical needs. We give attention to both needs," Jensen says.

The hospital has developed a healthcare benefits assistance program to help patients who are admitted without a payer sign up for Medicaid and disability benefits.

In fiscal year 2005, the staff took 1,918 applications for Medicaid. Of those, 1,348 or 70% were approved, resulting in more than $19 million to the institution. Of the 491 applications for disability payments, 75% were approved.

"These patients went from having no payer to having a payer," Jensen reports.

Staff are trained to take Medicaid and disability applications at the bedside.

"The staff follows patients after discharge because it could take three to six months for the application to be approved. They assist with appeals if the application is denied," Jensen says.

In addition, three staff members coordinate a medication assistance program to identify whether patients are eligible for any pharmaceutical programs for the indigent.

"This has been helpful in terms of getting patients access to the medications they need to prevent a readmission. Lack of medication is a huge problem. If a patient can't get insulin or an IV antibiotic, we can't discharge them without their medication," Jensen says.

(Editor's note: For more information, contact: Greg Jensen, ACSW, LISW, e-mail: gregory-jensen@uiowa.edu.)