The average length of stay for patients with pneumonia, sepsis, and heart failure dropped by one day when a care coordinator was assigned to a hospitalist group and followed its patients throughout the hospital stay during a pilot project at Sentara Princess Anne Hospital in Virginia Beach, VA.
When Sentara Healthcare enacted a pilot project in which a care coordinator was assigned to a hospitalist group and followed patients throughout the hospital stay, the average length of stay for patients in the program dropped by one day.
- One care coordinator was assigned to two to three hospitalists and had a caseload of 20 to 23 patients with pneumonia, sepsis, or heart failure and other patients determined to be at high risk.
- Care coordinators meet with hospitalists each morning to review patients likely to be discharged that day, meet again during multidisciplinary rounds, and communicate constantly during the day.
- Other initiatives include providing box lunches for patients discharged around noon and establishing a team of discharge facilitators in a central location to send referrals to post-acute providers and set up transportation.
“While this is just one of the strategies we utilized for length-of-stay management, the ability to have concurrent reports and ongoing physician communication has made a huge difference,” says Teresa Gonzalvo, RN, BSN, MPH, CPHQ, ACM, vice president for care coordination for Sentara Healthcare, with headquarters in Norfolk, VA.
Based on the success of the pilot, the health system has rolled out the model on Sentara Princess Anne’s medical-surgical and step-down units. The care coordinators are working with three physicians who are part of Sentara Medical Group and Bayview Medical Group, she adds.
The health system is moving toward rolling out the model in the other seven hospitals, she adds.
Sentara’s unit-based/dyad model of care coordination assigns care coordinators and social workers by geography. In that model, when patients are transferred to a different unit, their care is coordinated by a different set of care coordinators and social workers, Gonzalvo says.
“With the focus on patient-centric strategies, heightened awareness of value-based purchasing and other healthcare reform initiatives, the health system created a high-performance design team with the goal of determining ways to better manage patient transitions across the continuum,” Gonzalvo says.
The team decided to try a hybrid pilot project that aligns care coordinators and physicians, she adds.
“The model aligns with the system goal of being more patient-centered and communicating more effectively with the patient, family members, and other healthcare providers across the continuum of care,” says Pat Vajda, RN, BSN, CCM, manager for care coordination at Sentara Princess Anne.
The pilot project at Sentara Princess Anne Hospital assigned one care coordinator to a group of two to three hospitalists with a caseload of 20 to 23 patients. When the caseload got higher, another care coordinator was assigned to help out.
“We couldn’t include 100% of patients, so we concentrated on the three clinical conditions where there was a lot of opportunity—pneumonia, sepsis, and heart failure. The care coordinators assess every patient and focus on the patients who need services,” Gonzalvo says.
After the success of the pilot, the team developed a business plan to replicate the model throughout the health system, Gonzalvo says.
When developing the business plan, the team looked at the volume of patients that the care coordinator was able to impact. “We looked at patients who were risk-stratified based on the three targeted diagnoses plus readmitted patients, those with complex conditions or comorbidities, those who were frequently admitted or those with social issues. We are concentrating on those at high risk,” she says.
The ultimate goal is to assign each care coordinator to one physician supporting the individual hospitalists’ patients. The social workers will remain unit-based, Gonzalvo says.
“It’s a hybrid model. We are starting slowly. The care coordinators and physicians are not aligned throughout the hospital system yet, but we are getting there,” she says.
The result is a more patient-centered model, she says. The care coordinator follows the patients wherever they go while they are in the hospital.
“While traveling through the hospital can be an issue, the use of technology, the electronic medical record and our case management application, are critical success factors and major drivers for efficient and effective workflows,” Gonzalvo says. The case managers use workstations on wheels at one hospital. The health system has plans to install these at other hospitals when the capital budget is approved, she says.
“The care coordinator becomes a familiar face to the patient and family member,” she says.
The arrangement has led to enhanced communication between the hospitalists and the care coordinators, resulting in better care for patients and improved throughput, says Albert I. Soriano, MD, FACHE, co-clinical chief of hospital medicine at Sentara Princess Anne.
“In the past, we typically worked with more than one care coordinator. Now, the hospitalists have a close working relationship with the care coordinator assigned to them. There’s always a proactive conversation about where patients are going after discharge and what their needs will be, and that’s what’s driven the length of stay down,” Soriano adds.
When they arrive in the morning, the care coordinators review the charts of patients in the hospital, set priorities, and come up with the plan for the day. “They look at the patients who were scheduled for discharge but are still in house and see what occurred to keep them in the hospital,” Gonzalvo says.
The care coordinators meet with the hospitalists to whom they are assigned each morning and review the patients likely to be discharged that day or the following day and determine what needs to happen to expedite the discharge, Soriano says. They meet again during multidisciplinary rounds that include nursing, pharmacy and representatives from other ancillary departments and review all the patients on the floor and discuss transition plans for the next day as they evolve.
“We are in constant communication as the day progresses. I may walk into a room and find that the patient is better than I expected. Then I’ll call the care coordinator on the phone and tell her that Mr. Smith is ready to go home. She can start taking care of his discharge needs right then and there,” he says.
In the past, physicians would write the order for discharge on the chart but it might be hours before someone saw it. “During that time, somebody could have been ordering durable medical equipment, or ordering transportation. Being in constant communication expedites things tremendously,” Soriano says.
To further expedite discharge, the hospital has arranged for dietary to have box lunches available if the patient is discharged around lunch time, Gonzalvo says.
In addition, a team of discharge facilitators in a centralized location sends referrals to post-acute providers and schedules transportation ahead of time. The arrangement allows care coordinators and social workers to spend more time with patients, families, and physicians, instead of being bogged down with administrative tasks, she adds.
“We have made a concerted effort to look at avoidable days and troubleshoot to avoid them,” she says. For instance, if the physician has ordered a consultation that hasn’t taken place, the care coordinator gets in touch with the consultant and determines what has happened.
“The same hospitalist-care coordinator team works together all the time. Everybody knows everybody, and they communicate well. They all have the same goals. When the care coordinator at Princess Anne took a few days off, the hospitalists all said they missed her,” she says.
When patients are admitted, the care coordinators perform an initial assessment within the first business day and develop a transition plan and length-of-stay target.
If patients are not able to be transitioned after the estimated length of stay, the care coordinator analyzes why. If it was a true avoidable delay, such as services were not available over the weekend, the care coordinator documents it. The avoidable delays, and ways to avoid them, are discussed with the hospitalists and at multidisciplinary rounds, Gonzalvo says.
When patients are readmitted, the care coordinators perform a readmission assessment along with the initial assessment. “We are trying to get information up front as we move forward with transition planning and preventing readmissions,” she says.
The entire care coordination leadership team receives weekly reports on avoidable delays, daily census, discharge dispositions to skilled nursing facilities and home care agencies, as well as readmissions, Gonzalvo says.
The Hampton Roads Long-Term Care Council, composed of community and Sentara post-acute providers, works collaboratively on care transitions. In addition, the hospital’s Utilization Management Committee meets monthly and discusses trends in transitions and readmissions.
“Patient-focused communication, information management, teamwork, resource management, and post-hospital transition planning all contribute to our successful care coordination initiative,” Gonzalvo says.