Maintaining good patient flow is more important than ever as CMS and other payers move toward payment reform basing reimbursement on the entire episode of care.

  • Making sure patients move smoothly through the continuum is part of the case manager’s responsibilities and is essential to the hospital’s bottom line.
  • Complete patient assessments and start discharge planning on Day 1, or before the patient arrives if the admission is planned, to eliminate last-minute problems that contribute to avoidable delays.
  • Establish what happens during every step of the hospital stay, identify where the bottlenecks occur, and take steps to make improvements.
  • Case managers should cover all access points to ensure admitted patients meet inpatient criteria and arrange services at another level of care if they don’t.

In the ever-changing healthcare world with new focus on reimbursement for the entire episode of care, penalties for hospital readmissions, and questions about inpatient versus outpatient status, case managers still need to be concerned about moving patients through the continuum as quickly and safely as possible.

The healthcare system is rapidly changing, but the need to manage length of stay hasn’t changed, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

“With payment reforms such as bundled payments and Medicare spending-per-beneficiary, hospitals still have to manage length of stay. In a true case management model, one of the roles of case managers is to manage patient flow. Case managers have an obligation to identify delays and work to eliminate them,” she says.

Eliminating avoidable days is still a good way for hospitals to recover revenue and to use their resources more efficiently, adds Bonnie Barndt-Maglio, PhD, RN, managing director of Chicago-based Prism Healthcare Partners. “New regulations from CMS and other initiatives such as bundled payments and the readmission reduction program are getting a lot of attention, but the foundational work of case managers is to address excess days,” she says.

“When hospitals take on more risk, whether it’s through bundled payments or other forms of reimbursement, patient flow has a huge impact,” says Connie D’Argenio, MS, BSN, managing director of Huron Healthcare Practice at Chicago-based Huron Consulting Group. “Good patient flow and optimal use of the inpatient setting are essential components of an effective bundled payments strategy. Managing the placement and transition of patients is part of a case manager’s responsibilities and it can affect the hospital’s success,” she says. (For tips on improving patient flow, see article in this issue.)

Hospitals need to have a process in place to ensure on a daily basis that care is being progressed, including whether the patient is receiving the appropriate level of care, D’Argenio says.

Not only do timely discharges benefit the hospital’s bottom line, it benefits the patients as well. “Patients can pick up an infection in the hospital, and the sooner patients are back in their own environment, the sooner they recover if they have a good discharge plan and all the services they need are in place,” Barndt-Maglio says.

Historically, case managers have been the ones who were responsible for making sure care is progressing, reducing fragmentation, and ensuring everybody on the treatment team is moving in the same direction, adds Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.

“That hasn’t changed, and case management is more necessary today than ever before. People are beginning to appreciate the value that case managers bring to healthcare and the role that nobody else fills. At the same time, the responsibilities are increasing and we’ve seen an increase in the number of tasks case managers have to juggle,” Owen says.

In fact, as changes in the healthcare system have changed the scope of the job for case managers, the term “care manager” is more appropriate, adds Mark Krivopal, MD, MBA, vice president at GE Healthcare Camden Group in Boston.

“Case managers traditionally have concentrated on the inpatient stay, but the role is evolving to the role of ‘care manager’ who looks at what’s happening at all points in the episode of care,” he says.

Good patient flow in the inpatient setting remains critically important, and reducing avoidable days is gaining in importance as payers move toward global payments, Krivopal adds.

Hospitals often begin initiatives to improve throughput because of long waits for beds in the ED or surgery recovery area, Barndt-Maglio says. “But the emergency department and operating room are not the cause of the problem — they are the victims of bad patient flow. If admitted patients get the services they need and are discharged in a timely manner, it opens up inpatient beds for more patients,” Barndt-Maglio says. (For information on how having case managers in the ED can improve patient flow, see related article in this issue.)

Barndt-Maglio estimates that 80% to 90% of avoidable delays occur during patient stays of 0 to 5 days.

One of the most common delays is execution of the discharge plan in a timely manner, she says. Delays may occur as the discharge day approaches. It may be that the patient doesn’t have transportation home, or the family hasn’t chosen a post-acute facility, or the physician is waiting on a test or an evaluation.

“Case managers can’t move patients through the continuum alone. They should develop a strong relationship with their hospitalist team and the rest of the interdisciplinary team and work together on patient flow,” Barndt-Maglio says.

Take a proactive approach and assess patients as soon as they come into the hospital and start to work on the discharge plan, Barndt-Maglio suggests.

“If case managers understand the patients’ needs on day one, they can arrange for services early in the stay and not wait until the last minute, delaying discharge,” she says.

Patient flow initiatives should start even before patients come to the hospital, when admissions are planned, Krivopal says.

Traditionally, when hospitals looked at patient flow, they focused only on the time the patient was in the hospital, Krivopal says. “This is still important, but as we move into more sophisticated alternative payment models, the management of patients and oversight of what happens has to extend outside the hospital,” he says.

For instance, when elective surgery is scheduled, care managers should conduct a comprehensive patient assessment that includes screening for comorbidities, living situation, support system, and potential discharge needs so care managers will have the information needed to start the discharge plan. If the patient is likely to need post-acute care, the care manager can start the process of identifying a facility that will meet the patient’s needs and is approved by the family, he says.

“A lot can happen prior to the patient actually arriving at the hospital that will have an impact on patient flow. Assessing patients in advance is a new concept, but one that can move the patient efficiently through the continuum and reduce potential readmissions,” he says.

If patients already know the expected length of stay and their discharge destination before the surgery, they can have their transportation and support lined up. If they choose their post-acute provider, the case managers can line up the services in advance and avoid scrambling at the last minute.

The interdisciplinary team should set the patient’s expected discharge date the first time they round on a patient and update it as needed and inform the patient and family, Owen says.

“The discharge date is not set in concrete, but the care manager should lead the team in accomplishing what needs to be done to hit that date whenever possible,” Owen says.

“Case managers lead the interdisciplinary team, but they also are the liaison between the finance team and financial counselors from a reimbursement perspective,” Owen adds. For instance, the patient may need to complete an application for Medicaid or assistance from community resources. If the patients aren’t able to understand the plan of care and have no family support, they may need a court-appointed guardian.

Both examples can take weeks or even months to accomplish, Owen says.

“A lot of factors play into transitions of care, and there may be issues besides the patient’s healthcare that have to be managed. It is the responsibility of case managers to keep everything moving,” Owen says.

But don’t get carried away with moving patients along, Krivopal warns. “The key in both creating and restructuring care under global payment is focusing on the patient from inpatient to home as well as from the ED to inpatient. If patients are at risk for readmission, it may be that an extra day makes sense from both a patient care side and the financial side,” he adds.