By Toni Cesta, PhD, RN, FAAN

Introduction

The term “transitions in care” has become an important talking point for value-based purchasing, the Affordable Care Act, accountable care organizations, and bundled payments. The concept of transitioning patients also is critical to the field of case management and has been a process that we have owned for many decades. With the advent of the changes listed above, it has become clear that case management often is the driver of transitions in care. This month, we will discuss two important tools that case managers can use to improve their patients’ transitions in care — the admission and discharge time-out processes. These processes can be hardwired and used to facilitate internal and external patient transitions and handoffs.

Hospital Transitions: The Past

Prior to the changes listed above, the hospital transition process was fairly straightforward, with little deviation or variation. The patient was admitted to the hospital through the ED or via a planned admission or transfer. He or she spent a period of time in the acute care setting, including a period of extended stay in the ICU or a medical floor. The goal was for the patient to recover from illness or surgery prior to the discharge home. Home was the usual and customary discharge destination. On occasion, the discharge home might have included home care for a short period of time.

This simplistic example of how patients transitioned in the past illustrates the minimum number of handoffs required by case management staff during the acute care phase of illness. In those days, there were virtually no case managers in the ED, so there were no handoffs there. In addition, many departments were so grossly understaffed that handoffs were a luxury, only used for the most extreme cases where information-sharing was absolutely necessary.

Transitions Today

Today, case managers and social workers have many partners in the care transitions process, including post-acute care providers, physicians, patient-centered medical homes, home care case managers, and many others. We can no longer consider our work completed when the patient leaves the hospital. We must ensure that the arrangements we have made for the patient in the home are delivered timely and as planned. We must have an eye on the continuum of care and the availability of community-based resources from a much more global perspective then we did in the past. We must advocate for our patients and resolve gaps in the transition processes when necessary.

The American Case Management Association (ACMA) provides guidance in their standards of practice for transitional coordination of care. According to the guidance, transition management begins at the time of the case manager or social worker’s initial patient encounter. It explains that the transition management plan must be re-evaluated and adjusted throughout the patient’s stay. It recommends that electronic, telephone, or in-person contact be made with the patient within 72 hours of discharge from the hospital.

Today, our transition plans include more than just the discharge plan — they must also include the patient’s risk for readmission in concert with their discharge needs, as these two elements of the plan should be carefully synchronized. When patients are determined to be at high risk for readmission, the case manager must apply post-acute interventions to proactively reduce the likelihood of that patient returning to the ED and/or the hospital.

Admission and Discharge Timeouts

Admission and discharge timeouts are an example of strategies for improving the effectiveness of your transitions. The admission timeout occurs once the patient has been transferred to the inpatient unit. The discharge timeout happens once the discharge plan is finalized, but before the patient leaves the hospital.

The Society for Hospital Medicine has called for what they call nonprocedural timeouts. Procedural timeouts are those that happen before a procedure or surgery. Nonprocedural timeouts are innovative communication tools that can potentially limit communication failures that might occur at critical transition points. (For more information on nonprocedural timeouts, visit: http://bit.ly/2uPijM2.) Let’s review how each of our case management timeouts work.

Admission Timeout

The admission timeout is performed once the patient has made it to his or her inpatient or observation bed. It’s a multidisciplinary process that can include the patient, family, and family caregivers. Many members of the care team are stakeholders in the admission timeout process. These include the physician, the case manager, the social worker if assigned to the case, the staff nurse, and clinical documentation improvement staff.

The goals of the admission timeout are to identify risk during the hospital stay and to prepare for discharge, and include the following risk assessments:

  • readmission;
  • quality metrics;
  • financial metrics;
  • care coordination;
  • compliance;
  • patient experience;
  • clinical documentation metrics;
  • potential transition gaps.

The admission timeout can be coordinated by various case managers, depending on where the patient is located. For example, the ED case manager can complete the readmission risk assessment and evaluate for any gaps in transition during the initial assessment process.

The perioperative case manager can perform the timeout prior to elective or emergent surgeries. The unit-based case manager can perform the timeout on both admissions and observation patients.

The admission timeout process is not a sit-down meeting — it is a process that can be completed by multiple team members.

Components of the Admission Timeout

The components of the admission timeout do not need to be completed in any particular order, but all must be addressed. Medication reconciliation is one that needs to be completed on admission, as this is as vital as the medication reconciliation performed at discharge. If the admission medication reconciliation is not done, there is an increased potential for errors to occur during the hospital stay. These errors will then translate to errors at the point of discharge.

The case manager’s role is to identify any transition opportunities or concerns. These would include issues that might occur during the hospital stay or post-discharge. The case manager and social worker also should perform an admission risk for readmission assessment. Best practice would be to perform this assessment as part of the case management admission assessment and to embed the questions in the admission form. Once the readmission risk assessment is complete, the case manager and/or social worker should initiate a plan to address the cause or causes of the readmission. For patients presenting to the ED who will not be admitted but may have frequent visits or previous admissions, the ED case manager should complete a similar risk assessment and plan of correction. This may include a referral to home care or to a community-based case manager.

During the admission timeouts, other quality of care-related elements should be reviewed. These might include process of care measures, safety indicators, present on admission documentation, and medication reconciliation.

From a financial metric perspective, the following should be reviewed during the admission timeout process:

  • Review medical necessity and Two-Midnight Rule documentation.
  • Review plan of care to ensure that it is focused on the patient’s reason for admission and refer to clinical documentation if necessary.
  • Identify any specific contractual requirements for commercial payers, managed Medicare, or managed Medicaid.
  • Identify any potential transition gaps, particularly in unfunded or underfunded patients.
  • Determine if the patient is at high risk for a long length of stay and/or high cost during this hospitalization.

From a coordination of care perspective, the following should be reviewed:

  • the plan for the day;
  • the plan for the stay;
  • case manager assessment for potential referral to social work and home care;
  • the anticipated date of discharge — communicate this date to the patient and family and keep them involved in the discharge planning process to ensure that they are ready for discharge on the expected date;
  • potential need for a case conference.

Finally, compliance measures should be reviewed. These include the following:

  • appropriate admission order, including the level of care;
  • medical necessity to ensure compliant billing and reduce the possibility of a denial;
  • Two-Midnight Rule requirements;
  • patient choice for home health or skilled nursing facility, if appropriate;
  • anticipated discharge plan.

It is wise to consider implementing a process that includes the patient and/or family in the admission timeout process. During admission is an opportune time to see the patient’s family. It is also a good time to determine if there are any family caregivers already involved in caring for the patient. The initial discharge plan can be shared with the patient and/or family at this point. It also is a good time to write the anticipated date of discharge on the whiteboard, if available.

Discharge Timeout

One of the major weaknesses of the discharge process is the relative lack of attention to detail from the patient’s interdisciplinary care team at the time of discharge. While there is a great amount of attention to the patient at the time of admission, this amount of attention does not translate to the discharge process in the same way. Discharge timeouts are just as critical and answer the following questions:

  • Has everything needed for discharge been performed correctly?
  • Have all the patient’s needs been addressed? (Including needs related to admission and other needs that can be addressed after discharge.)
  • Has the patient’s discharge plan been reviewed and all post-discharge needs addressed?
  • Has the patient been educated on their medications?
  • What was the patient taking on admission?
  • What, if any, are the changes in medications for discharge?
  • Have the patient and family agreed to the discharge plan and destination?
  • Have they been educated to everything they need to know regarding care at home?
  • Are all post-discharge arrangements in place?
  • Have the medications been reconciled?
  • Does the patient have a primary care provider?
  • Does the patient have a follow-up appointment with his or her primary care and/or specialist within seven to 10 days after discharge?
  • Does the patient have a written plan outlining the follow-up appointment?
  • Does the patient have transportation to the appointment?
  • Have you completed a discharge readmission risk assessment based on the admission readmission risk assessment and any additional changes that may be relevant?

Components of the Discharge Timeout

During the discharge timeout, you should review the admission metrics we discussed above. When giving final instructions, educate the patient on the factors that contribute to readmission risk and what he or she can do to reduce the likelihood of another unnecessary readmission.

From a quality of care perspective, the following should be reviewed. Each member of the interdisciplinary care team plays a specific role in addressing each of the following indicators:

  • Medication reconciliation: 15-30% of patients will have a medication discrepancy during hospitalization. Patients with medication discrepancies are twice as likely to be readmitted. Age, high-risk medications, and polypharmacy issues should be reviewed as these also will contribute to an increased potential for readmission. This function typically is performed by a physician or midlevel practitioner.
  • Final documentation of process of care measures and patient safety indicators.
  • Make discharge summaries available to the primary care physician for the patient’s follow-up visit.
  • Primary care providers should be aware of any pending test results expected to arrive after the patient’s discharge.

From a financial perspective, review the following:

  • Be sure that all days have been authorized for commercial payers, including managed Medicare and managed Medicaid.
  • Finalize documentation with the physician of record to ensure that medical necessity is reflected in the medical record.

From a coordination of care perspective, be sure that the following have been addressed:

  • that a follow-up phone call is in place;
  • that a follow-up appointment is in place within 7-10 days;
  • community physician lead identified and in place;
  • appropriate discharge plan has been activated.

Compliance requires that the following be checked and confirmed:

  • delivery of the second Important Message from Medicare;
  • an appropriate process was used, should the patient appeal the discharge;
  • patient choice was documented in the medical record.

Time to Complete Admission and Discharge Timeout

Many interdisciplinary team members may have concerns about the time needed to conduct the timeouts and may feel that they simply can’t fit them into their daily routines. In reality, these processes can be timesavers and assist in improving the efficiency of the discharge process by hardwiring and standardizing it. If a template is used, the timeout can be finished as the various actions are completed.

The following are some timeout communication strategies to improve efficiency:

  • Include the patient and/or family in the process.
  • Let the patient know you are specifically focusing on his or her admission and discharge during these timeouts.
  • Each profession should discuss strategies after the admission timeout to coordinate, and not fragment, care planning.
  • Plan with multidisciplinary team when admission and discharge timeouts will occur.

Before you implement a timeout process, create a development and implementation plan for each timeout. Follow the items as listed below to guide your plan of action.

  • Determine which patients need discharge timeouts.
  • Determine the role of each of the multidisciplinary team members.
  • Develop a process to evaluate gaps in ability to implement admission and discharge timeouts.
  • Audit effectiveness at least monthly.
  • Share results of audits.
  • Improve the processes, based on the audit results.
  • Consider creating a multidisciplinary team to oversee the process.
  • Plan for each process, including education and implementation.
  • Evaluate the process as it rolls out.
  • Audit the effectiveness of timeout processes.
  • Determine which patients need admission and/or discharge timeout.
  • Consider starting with pilot units or patient groups.
  • Establish a plan for education that can be replicated.
  • Emphasize focus of timeouts during annual National Time Out Day (June 8).

How to Audit Your Timeout Processes

As discussed above, audit a sample of patients each month. Track the number and percent of patients with documented admission and discharge timeouts. Do these percentages match the predetermined percentages? For example, do you expect that all patients have a documented timeout, or some subset of all patients?

Compare patients with documented admission and discharge timeouts with the number of days delayed. Hopefully, you will see this number go down over time. Do the same for readmitted patients.

If you have a readmissions dashboard, you might consider adding the following:

  • percentage of patients readmitted with no admission timeout during previous admission;
  • percentage of patients readmitted with no discharge timeout during previous admission;
  • percentage of all-cause readmissions before and after timeouts implemented.

Summary

As case management becomes more and more complex, each department must develop the best, most effective strategies for staying ahead of the game. Admission and discharge timeouts are one example of a low-cost, successful intervention that can mean positive results for the case management department, the interdisciplinary care team, and the patients.