Timely and safe discharges are more important than ever in today’s healthcare world, but an increase in complex patients makes creating a discharge plan a challenge.

  • Start planning on day one and identify the patients whose discharges may be challenging and any roadblocks to moving to the next level of care.
  • Refer the cases that will take a lot of time to a discharge planning specialist whose sole responsibility is to move patients along.
  • Think outside the box to identify funding sources and other options for patients who no longer meet inpatient criteria, but have needs that make a safe discharge a challenge.

Does creating discharge plans for hard-to-place patients feel like a Sisyphean task — like rolling a boulder uphill, only to have it roll back down?

That’s how Carolyn Hamilton, MS, RN-BC, CDDS, CPHQ, corporate director of care coordination for DCH Health System, describes the challenges case managers regularly face when creating discharges plans for difficult patients.

“The most significant way hospitals have to control costs is controlling length of stay. This means that creating a safe and effective discharge plan is of utmost importance, but discharge planning is becoming more complex and more difficult,” Hamilton says.

Acute care hospitals are the only healthcare entities that are required to take every patient who comes in the door, Hamilton points out. And there are likely to be patients who stay after they no longer meet inpatient medical necessity just because of difficulties in carrying out a safe discharge plan.

DCH Health System is a three-hospital system, with headquarters in Tuscaloosa, AL. The three hospitals have a total of 859 beds and treat about 1,200 trauma patients a year and experience more than 750 serious trauma alerts.

In addition to the trauma patients, other patients presenting a challenge for a safe and timely discharge plan include patients with a criminal history, patients who need a guardianship, unfunded patients, those who want to stay when they no longer meet medical necessity or for whom there is a discharge order, or patients from another state or country who need post-acute care, Hamilton says. (For tips on planning discharge for challenging patients, see related article in this issue.)

“We discharge about 150 patients every day to create open beds for patients who need them. We have to move aggressively and discharge patients who no longer need to be in an acute care setting,” she says.

The first step in facilitating difficult discharges is to identify patients as early as possible in the hospital stay, says Cheri Bankston, RN, MSN, senior director of clinical advisory services for naviHealth, a Cardinal Health company. “There are a lot of readmission risk assessment tools available, but they don’t all focus on patients’ post-discharge needs and some patients may fall through the cracks,” she adds. For example, a previously independent patient with few comorbid conditions and no previous hospitalizations might not score high on a readmission risk tool that doesn’t take into account the patient’s current diagnosis or procedure, socioeconomic factors, or potential acute needs at discharge, she says.

She recommends that case managers look for risk assessment tools that also assess patients’ post-acute needs. Some tools that can be embedded in the nursing assessment will automatically flag patients who may have discharge needs and alert the case management staff.

Case managers should assess each patient early in the stay and create a plan, taking into consideration family support, the patient’s own view of his or her health, any mental health issues that affect adherence, and other potential roadblocks to a successful discharge, Bankston says.

Medicare Conditions of Participation require hospitals to develop safe discharge plans, Hamilton says. “This is not a suggestion — it’s a regulation that hospitals have to comply with, and planning a safe discharge has to begin on day one,” Hamilton adds.

She points out that the mean length of stay for all Medicare admissions is about 3.01 days. “When patients stay only three days, case managers have got to start planning the discharge as soon as they come in. If discharge planning doesn’t start the day of admission, the case manager will often be behind,” she says.

A multidisciplinary length of stay committee to review the patients with long stays is an effective way of identifying patients with complex discharge needs and targeting them for intensive discharge planning, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

She recommends that the committee review stays exceeding seven to 10 days and refer appropriate ones to a discharge planning specialist, an experienced social worker, or RN case manager who handles the difficult discharges. (For more on the role of discharge planning specialist, see related article in this issue.)

“If someone intervenes during that time frame, they usually can start moving the patient along the continuum and prevent a longer stay. Otherwise, the patient may languish indefinitely,” she says.

Bankston recommends that in addition to reviewing long-stay patients, the committee should analyze the hospital’s long-stay patients for patterns and create protocols that case managers can use to expedite the discharge of certain patients, such as those without funding.

For example, a patient who is ready for discharge may need IV antibiotics for a while after discharge, but doesn’t have funding for home health services. Instead of keeping the patient until the committee meets, the protocol could give the case manager the authority to make arrangements for the services under a defined dollar amount and pay for it out of a discretionary or charity fund. “Having a ‘hotline’ to the chief financial officer or designee can help determine the cost-benefit analysis of using funds versus keeping the patient in acute care,” she adds.

Committees meet only once a week or less frequently, Bankston points out. “If case managers have the power to make decisions or arrangements up to a point, patients can be discharged to the next level of care, opening the bed for another patient,” she says.

For instance, rather than waiting a week for the committee to make a decision, a case manager could negotiate rates with a skilled nursing facility or arrange for home health and other services, Bankston suggests.

“What we want to avoid is having decisions made at such a high level that there are delays of care, or that patients stay when they no longer meet inpatient criteria,” she says.

Case managers should research the resources in their communities and state, and bring in community leaders to find out what is available for patients who need post-acute support, Bankston says.

An in-house committee can review community resources and develop plans for handling the challenging discharges that occur most frequently, Bankston says. Include representatives from all disciplines, someone from administration, and the hospital legal department, she says.

Bankston recommends partnering with primary care and other providers who can treat patients with limited or no resources for post-acute care.

Get out and visit the post-acute providers and any other community resources, advises Marcy Pressman, deputy executive director of NYC Health+Hospitals/Bellevue, part of the city’s public healthcare system, which includes acute care and post-acute facilities in the five boroughs.

“The visits will give hospital staff a good understanding of what is available and build relationships with the post-acute facility staff,” she says. (For information on how the staff at Bellevue teamed up with NYC Health+Hospitals/Coler, a post-acute facility that provides short-term rehab and long-term skilled nursing services, see related article in this issue.)

Involve the patient and family in the discharge plan, Pressman suggests. “Find out what patients think they need. It may be different from what the treatment team thinks,” she says.

Invite representatives from post-acute providers to visit your hospital and assess patients who may be appropriate for their facility, Pressman suggests. “They may be more willing to take difficult patients if they can see them in person rather than just looking at documentation,” she adds.

At the same time, when patients and family members meet the people who will be providing their care, they are more inclined to accept the placement, she says.

Communicate with case management colleagues at other acute care facilities and brainstorm on how to find resources for difficult patients, Bankston says.

“Case managers tend to feel like they’re operating in silos, but professionals across the country can reach out through professional organizations and find out how their peers have handled particular situations,” she says.

Always have a backup plan, Hamilton advises. “The best plans may not work out sometimes. If you don’t have a backup plan, you can get into trouble,” she adds.

Use data to determine the most cost-effective options for patients with multiple diagnoses and/or high charges, Cesta suggests.

“If a patient is using a lot of hospital resources, it could be cheaper to pay for home care, rehabilitation, or a subacute stay,” Cesta adds. She suggests performing a return on investment analysis to see if there is a more cost-effective option than a longer hospital stay.

Good data can persuade post-acute providers to change their mind and accept a complex patient, Hamilton says. For instance, skilled nursing facilities often lose money when they administer IV antibiotics. Hamilton points out that once the treatment is completed, the facility no longer will be losing money and helps them conduct a cost-benefit analysis to prove the point.

In another situation, Hamilton might have her director of physical therapy call the facility’s director of physical therapy to discuss the patient’s needs. Often, the reimbursement for the physical therapy might offset the loss on the antibiotics, she says.

“Skilled nursing facilities are in the business of providing healthcare and they are looking for patients. The cost-benefit analysis helps them see the benefit of taking our patients,” she says.