Discharge planning has become a much more complex and challenging process — and a process it is! We can no longer think of it as a destination, but rather as a continuation of the care the patient has received. The discharge planning process must consider both the services provided to the patient before admission as well as those they will receive after discharge. It is a process, not a destination. Included among these patients are those most difficult to plan for: those patients who may linger in the hospital without intense and focused case management interventions and discharge planning.

This month, we will discuss ways in which your case management department can facilitate the management of these most complex patients. The interventions needed include both a process as well as a specialty position in the case management department to remove the undue and time-consuming burden of discharge planning of these patients to a dedicated provider. By providing this process, you can better ensure that these patients will receive the right care while in the hospital, and the most appropriate care they may need along the continuum as well.

Complex Discharge Planning and Long Length of Stay

The notions of complex discharge planning and long length of stay patients have become intertwined in our vernacular in case management. In fact, these may very well be two distinct groups of patients. You may think of them in this way:

Complex discharge planning patients: Patients with complex problems and issues that result in the need for extended and labor-intensive discharge planning.

Long length of stay patients: Patients whose length of stay has exceeded a pre-established length of stay benchmark.

Let’s start off by describing each group of patients.

Complex Discharge Planning Patients

First, the complex discharge planning patients. These are the patients who are difficult and time-consuming to plan for, and create, a discharge plan with a viable destination. The reasons for this can be varied. Examples might include the following:

  • undocumented,
  • uninsured,
  • underinsured,
  • John or Jane Doe, and
  • highly medically complex.

These patients can absorb large amounts of time from both the RN case manager and the social worker in the process of facilitating a discharge plan. While the RN case manager and the social worker are working on these patients, other more routine patients may be neglected or overlooked. This can result in a trickle-down effect whereby the length of stay can go up for all the patients in that RN case manager or social worker’s caseload. For this subset of patients, it makes good sense to move them to the caseload of a dedicated discharge planning specialist. This allows the more routine patients to continue to move through the acute care continuum in a more timely fashion. We will discuss the role of the discharge planning specialist shortly.

Complex patients who fall into this grouping may or may not have a prolonged length of stay. However, by getting to their plan earlier and by assigning a dedicated social worker or RN to manage their discharge planning needs, you can better ensure their discharge planning needs are met in a more efficient and timely manner.

The other subgroup of patients is the long length of stay patients.

Long Length of Stay Patients

The notion of having a discharge planning specialist serves to try to avoid having long length of stay patients whenever possible. Getting to these patients early and intensively can result in reduction of the volume of these patients. Even with this role in place, there will still be some patients who exceed your hospital’s definition of “long stay.” Therefore, in describing and identifying these patients, you must first know what your hospital’s definition of long stay actually is. By using this as a frame of reference, you can subset these patients more easily for intensive intervention by the discharge planning specialist.

How to Identify Long-Stay Patients

Acute care length of stay has to do with the amount of time allotted to the diagnosis, care, treatment, or recovery of a patient. All members of the healthcare team own these patients and have a responsibility in assisting in managing their length of stay. This responsibility does not belong to the case management department alone. Variation in care can contribute to extended lengths of stay as well as other factors such as lack of coordination and facilitation of care, delay in service, or high clinical complexity.

What defines a long-stay patient in your hospital, or any hospital? This definition should typically be based on determining how many excess days define about 20% of the population in your hospital. Excess days refer to the days beyond the patient’s expected length of stay as defined by their DRG. This is a calculation that your case management department will only have to figure out once and re-evaluate on an annual basis. If your average excess days per discharge average five days, then any patient with a length of stay of one day, or 20%, beyond the expected length of stay, would qualify for this category. The determination of the expected length of stay would be based on the presumptive diagnosis and the physician’s plan of care. Needless to say, when done concurrently, this is not an exact science.

You can also place patients into this grouping when it is clear they are going to become a long-stay patient based on the issues presented. This prospective approach can also contribute to a better management of their length of stay as you “get on the case” earlier. Both approaches should be used and it will get easier to identify these patients over time as you practice at it.

From here, you must then determine the causes of the excess days and create categories for them. If done correctly, you should be able to capture 80% of your long-stay patients with these categories and add others as needed.

Categories of Long-Stay Patients

The following is a suggested list of categories that are common to long-stay patients. You can add or subtract from this list as you better identify who your long-stay patients are and the causes of their extended stay.

Acute: Patient meets acute care criteria, and the prolonged length of stay is medically necessary and appropriate.

For this category, use your pre-established criteria such as InterQual to determine whether the patient meets acute care criteria. This makes the decision objective and documentable.

Post-Acute Provider Availability: Specialty bed not available such as ventilator, dialysis, isolation or combination of these.

For this category, patients may be clinically ready to go but simply have no bed to go to.

Payer Issues: Delay due to payer approval or lack of coverage for the needed service.

This category includes both delays in processing caused by a third-party payer as well as patients who are underinsured or uninsured and may not have coverage for the post-acute services they clinically need. Third-party payers can delay due to Medicaid application delays, managed care approval delays, or delays in obtaining a bed through a preferred provider. You may want to break this category into two groups if these are common problems in your hospital.

  • Patient/Family: Issues that arise from the patient or family that cause an extension to the length of stay such as providing paperwork for a Medicaid application, a delay in selecting a post-acute provider or service, family unable to decide between level of care services such as home care versus sub-acute, and end-of-life decision-making such as ventilator removal.
  • Legal Issues: A delay due to legal issues such as guardianship determination, undocumented, or unidentified patients (John/Jane Doe).
  • Psychiatric Placement: Delays due to unavailable long- or short-term psychiatric beds or services.
  • Other: Issues that do not fall into any of the predetermined categories.

Once you have identified the categories you would like to use, you can catalog the patients into one of these groups. Each patient’s entry should include the reason for the extended length of stay, the length of stay (this will be a continuously changing number), and the plan to address the causes of the delay.

Placing your data into a graph or chart can also help with tracking. An example might be the use of a pie chart to demonstrate the volume of patients in the various categories. However you choose to identify and catalog your long-stay patients, the following strategies should always be incorporated into the process:

  • update your list of patients weekly,
  • catalog issues for future reference, and
  • report to utilization review committee monthly.

The Discharge Planning Specialist

Once you have identified your long-stay patients and your process for managing them, you must also think about who in the case management department is best positioned to carry them on a discreet and specialized caseload. This position can be filled by a social worker or a nurse case manager. It must be a dedicated position that is used only for this purpose.

The role should be filled by an experienced social worker or nurse who has extended experience in discharge planning. The person filling the position should also be a creative thinker who is excellent at problem-solving and who has good communication skills. The position also requires someone who is good at managing and reporting data.

The caseload for the discharge planning specialist must be fluid as it may be larger at some times and smaller at others. The average should be about 20 patients, but should be ultimately dependent on the complexity of the patients that the specialist is managing at any point in time. Once the specialist has been assigned a patient, he or she should complete a thorough intake or admission assessment. This assessment will provide the foundation for the identification and management of any barriers to discharge for that patient. The RN case manager should maintain responsibility for overall case management of the patient including utilization management, patient flow, and avoidable delay management.

The specialist also is responsible for documenting in the patient’s medical record as appropriate. Documentation should include the specialist’s assessment, plan of care, and expected outcomes. Ongoing documentation should be added as needed. In addition to the specialist’s documentation, the RN case manager may document in the patient’s record as well.

Long-Stay Rounds

The discharge planning specialist should also plan for, and lead, long patient stay rounds. The rounds should take place on a weekly basis with the goal of reviewing all aspects of the case with a pre-identified team. The purpose of the rounds is to work as a team to identify interventions and solutions to correct the issues causing the increased length of stay.

Members of the committee should include the following:

  • discharge planning specialist (chair),
  • director of case management,
  • manager of social work,
  • physician advisor,
  • finance department representative in charge of Medicaid applications,
  • finance department representative in charge of cost outlier determinations,
  • legal department as needed,
  • ethics department as needed,
  • hospitalist or physician of record as needed, and
  • family member as needed.

The discharge planning specialist should come prepared to present each patient on the long-stay list and to discuss the causes of the long stay and any interventions applied or plans to do so. The finance department should present the financial barriers to the patient’s discharge as well as the current charges applied to the admission. The team should brainstorm and identify any potential solutions not already applied by the specialist.

Some ad hoc members may be included as needed such as the legal department, ethics department, the patient’s hospitalist or physician of record as appropriate, and/or a family member. If a family member is included, the team should be as small as possible so as not to overwhelm or frighten the family member.

The following can be used to create your own job description for the discharge planning specialist:

JOB SUMMARY: This position serves as a resource to case managers and/or social workers working with complex to discharge patients. The discharge planning specialist carries a caseload of complex patients identified by day, dollar, or time intensity outlier designation. Analyzes data to understand the causes and corrective actions for this subset of patients.


  1. Focuses on the most complex, time-consuming discharge planning issues/patients.
  2. Selects patients from those exceeding the hospital’s self-selected long stay threshold.
  3. Manages these patients in conjunction with the RN case manager.
  4. Coordinates the discharge planning process for complex patients, including those with greater psychosocial acuity, or having time-sensitive needs.
  5. Serves as a resource to any social worker or RN case manager who has a complex patient requiring intensive discharge planning.
  6. Serves as a resource to city, state, national and international discharge planning challenges such as legal, police, and community liaisons.
  7. Collects and analyzes data regarding referrals and complex cases.


To summarize our discussion this month on long-stay patient management, below is a series of strategies for incorporation into your case management department’s processes.

Strategy #1: Identify Long Length of Stay Patients and Related Issues.

  • Define and select your long length of stay categories.
  • Select your target long length of stay metric/cutoff point.
  • Once patients exceed this benchmark, they should be reviewed more intensely.

Strategy #2: Review Length of Stay Issues During Interdisciplinary Care Rounds.

  • Discuss the expected against actual length of stay.
  • Share the prolonged length of stay issues with the team.
  • Even though the problem may not be immediately correctable, it still needs to be discussed each day so the team does not lose sight of the issue or the patient.

Strategy #3: Conduct Weekly Long Length of Stay Rounds.

  • Occur weekly in addition to daily rounds.
  • Focus on predefined long length of stay patients.
  • Attended by case management, social work, nursing.
  • Progress against corrective actions should be discussed.

Strategy #4: Implement Discharge Planning Specialist Position.

  • Select social worker or RN case manager to fill position.
  • Keep caseloads manageable.
  • Report data to utilization review committee.

Strategy #5: Determine Which Patients are Acute.

  • All non-acute patients should be referred to the discharge planning specialist.
  • This will help to offset the workload of the RN case managers and social workers.
  • For acute patients, the RN case manager should review daily to determine any changes in status that may require a change in level of care.
  • The earlier these patients are identified, the earlier the process can be initiated.