Multidisciplinary initiate cuts length of stay
CMs, RN, hospitalists collaborate on care
A multi-disciplinary initiative to make sure patients receive care in the right setting at the right time for the right reason has resulted in a drop in length-of-stay at the two hospitals in the Memorial Health Care System in Chattanooga, TN.
In the first year, the program, called Pace of Care, has resulted in a 1.6% drop in length of stay to 4.73 days at Memorial Hospital in Chattanooga, and a 4.75% decrease to a length-of-stay of 4.02 days at Memorial Hixson Hospital in Hixson, TN. "Case managers have always known that we can't manage the care of patients alone. It takes everybody in the hospital to make sure patients get the care they need in a timely manner. We are pulling everyone on the clinical team into managing the patient," says Demetra Reid, RN-BC, MSHA, CCM, case management director for Memorial Health Care System.
When the initiative began, the hospital system redesigned its case management department and almost doubled the case management staff from 22 to 43. The department includes RN case managers located in the emergency department and the intake department who review direct admissions from doctors' offices and patients who are scheduled for surgery. The initiative added masters'-prepared social workers to the team. They are assisted by discharge planners, who have a bachelor's degree.
It took approximately 10 months to a year to hire, train, and provide orientation for the new case managers and social workers. Then the focus of Pace of Care switched to other disciplines involved with patient care and throughput, including nursing, hospitalists and pharmacy. (For details on how the hospitalists and pharmacy are involved in Pace of Care, see related article, below).
Case managers are assigned by unit with a goal of a caseload of 20 to 25 patients, a decline of 37 patients per case manager before Pace of Care was implemented. Social workers typically work between two units with a caseload of 40 to 50 patients, a decrease from the previous 60 to 67 patients. Discharge specialists perform routine discharge planning, leaving the social workers to work on the more complex and time consuming psychosocial issues that may arise.
Case managers, social workers, and discharge specialists use a tool that lists the majority of potential patient needs, such as assessments, durable medical equipment, arranging for skilled nursing transfers and home health services, and for delivering the Important Message from Medicare. "As the day progresses, the case managers and social workers can consult the tool and check off what has been done and what needs to be done. Proper use of this tool means the team does not have to sit down together in order to maintain constant communication throughout the day," Reid says.
A key component of Pace of Care is multidisciplinary Touch-Base Rounds led by the case manager on the unit in patients' rooms by the second day of each patient's stay. The case manager, primary nurse, and social worker/discharge specialist introduce themselves, and discuss the plan of care documented by the physician in the medical record, along with the targeted day of discharge.
"The case manager makes it clear that the date is anticipated and that the discharge could occur before or after this time period. This is a good way to get patients involved in discharge planning while introducing the concept of discharge from the beginning of the stay," Reid says.
The team writes the anticipated date of discharge on a white board in the patient's room. "This keeps everyone focused. Nursing knows when to complete the patient education and the discharge planner knows when to set up what's needed after discharge. The doctors know when we expect the patient to be discharged and it gets us past times when patients just want to stay," she says.
The rounds are informational and quick and if patients have additional questions, either the case manager, the social worker/discharge specialist, or the nurse comes back and talks to them in more detail. The team has a goal of performing additional Touch-Base rounds every other day as well as when there is a change in the patient's medical condition.
The case managers review every medical record every day to ensure that the patient status is appropriate and that they meet continued stay criteria. The case managers open the record and review the orders to ensure that the appropriate order is on the chart. "This has alleviated situations when there were not orders for patient status on the record, or to allow for swift review and resolution of criteria for the correct status assignment, such as when the status was inpatient in the computer but observation in the actual medical record," she says.
For more information, contact
- Demetra Reid, RN-BC, MSHA, CCM, Case Management Director for Memorial Health Care System, Chattanooga, TN. E-mail: firstname.lastname@example.org.
Hospitalists, pharmacy collaborate on throughput
Through Pace of Care, the case management department at Memorial Health Care System in Chattanooga, TN, works closely with the hospitalist staff and the hospital pharmacy department to ensure that patients move through the continuum as quickly and safely as possible. Hospitalists care for about 60% of patients at Memorial Hospital in Chattanooga and 90% at Memorial Hixson in Hixson, TN.
Part of the efforts to fine-tune case management and hospitalist communication has been to implement case manager-hospitalist rounds, says Demetra Reid, RN-BC, MSHA, CCM, case management director. The case manager team leader or Reid rounds unit-by-unit with the director of hospitalists and discusses with the case manager on the unit, any barriers to the patient's safe and appropriate discharge. "We talk about how to expedite discharges so we can drop down our length of stay," she says. At times, the hospitalist director calls a member of the hospitalist team to discuss what clinically is taking place with patients. Other times, the case management supervisors get involved to remove barriers to discharge.
When the hospitalist rounds began, the team focused on patients who had been in the hospital 10 days or more, then began to include patients with seven-day stays. Now the rounds include patients who have been in the hospital for five days or more. "The high length of stay is decreasing which is a tribute to how effective the rounds are," Reid says.
"Communication with the pharmacy is important as there are multiple charity patients who may require medication assistance, or there are patients who could potentially go home or to a skilled level of care if their intravenous antibiotics were appropriately changed to another type," Reid says. Assistance from pharmacy has helped decrease length of stay, she adds. "Sometimes discharges are delayed because the physician orders IV antibiotics every eight hours and which would be difficult to arrange. The pharmacists may suggest appropriate alternative medications that can be given once or twice a day," she says.
Case management is a participant in a weekly high-dollar conference call with representatives from finance and the business office. The team reviews all patients whose current charges exceed $75,000, looks at the discharge plan, the anticipated discharge date insurance benefits, insurance network status, or self pay financial assistance. The team also looks at Medicare days for potential lifetime reserve days activity. "Since using Medicare life-time reserve days requires a patient's approval, this is important information to receive concurrently," Reid says.
The next layer of Pace of Care will be to develop relationships with the specialty physicians and help them understand changes in reimbursement and how they are impacting the facility. "We know that the healthcare system is evolving and that the resources are getting tighter. This means that we all have to work together to make sure patients get the care they need in an efficient and cost-effective manner," she says.