Case managers are a crucial component of programs to improve hospital discharge and bed flow efficiency.
One hospital has developed a nine-step program involving case managers to improve patient flow and discharge efficiency.
Here are the ways Michigan Medicine in Ann Arbor has improved its patient flow:
1. Case managers round with teams.
Case managers hold a daily conversation with members of the discharge team.
“They talk about which are the one or two patients that will be discharged tomorrow,” says Teresa Jacobs, MD, medical director of care management and professor of neurosurgery and neurology at Michigan Medicine, University of Michigan, in Ann Arbor.
Case managers always have been involved in this conversation of what a patient needs at discharge, but they now ask whether particular patients could be discharged in the morning, she adds.
“We now say, ‘Who can we realistically discharge tomorrow morning and get everything the patient needs by 11 a.m.?’” Jacobs says. “We didn’t change the amount of work everyone has to do, but we changed the times that they do the work.”
The rounds involve logistic discussions, including setting up lab orders for patients who will be discharged by 11 a.m. “We want those labs done first, making them available for the physician to evaluate in the morning,” she says.
“Instead of putting all labs in one giant order, we reprioritize the queue, and we talk with pathology and the lab to find a way to get a flag on those labs,” Jacobs adds.
2. Note changes on the progression board.
Case managers use a simple, color-coded system in the electronic health record to flag patients for discharge by 11 a.m. the next day, says Josh Thielker, MPH, senior project manager of care management at Michigan Medicine, University of Michigan.
For example, physical therapy staff might see 10 orders for physical therapy evaluations on any given day. Of those 10, three could be priority discharge patients. Physical therapists will prioritize their work to allow for rounds on those three patients first, he says.
Physical therapy evaluations were one of the most frequent barriers cited for an early discharge, Thielker notes.
Once physical therapy staff had access to the progression board and color-coded system, they were able to adapt easily to the change in priorities, he says.
“There was an adjustment period when we rolled it out, but the progression board helped them visualize the patient,” he adds. “And we found, quickly, they were taking care of those priority patients’ needs first without much difficulty.”
Before the change, various departments might prioritize patients arbitrarily, Jacobs says. “Instead of doing it alphabetically or by room — which is an arbitrary designation — we now have a priority list of how they get their work done.”
3. Ancillary services use list of priority discharge patients’ needs.
“The priority list is in the electronic health record with a visual indicator,” Thielker says.
Ancillary services, including physical therapy, occupational therapy, lab, social work, and others, use the list as early as 2 p.m. the day before the discharge.
“Case managers and their care teams are educated to identify appropriate patients for the morning discharge, and they can make the list no later than 2 o’clock,” he says. “We want to give our ancillary partners the maximum amount of time required so they do not delay discharge the next morning.”
It will not help to create a priority discharge list that is not available until early on the morning of discharge, Thielker notes.
“If we don’t get the order in for physical therapy evaluations until 9 the next morning, then it doesn’t give physical therapists adequate lead time to evaluate the patient,” he explains.
Making this cultural change required significant staff education, Jacobs says.
Nurses approved the education plan, which involved going to various units to help people understand the concept of discharging more patients in the morning.
“It’s a new way of thinking,” she says.
“We’re forcing teams to have conversations proactively the day prior to discharge,” Thielker adds.
4. Social worker and nurse meet in the afternoon to discuss the early discharges.
Nurses do not always agree with the physicians’ ideas of which patients could be discharged the next day before 11 a.m. Nurses can discuss specific concerns with the social workers.
“If there’s a barrier to the early discharge and the social worker tries to fix the barrier, but cannot, then the social worker will talk with the case manager and medical team,” Jacobs explains. “The patient might have to be taken off the list.”
But this scenario happens less frequently as the program evolves. “It doesn’t mean we don’t have priority discharge patients drop off the list, because we do, but the main reason is a medical status change, such as the patient overnight developing new nausea or vomiting or gastrointestinal bleeding,” she says.
Once everyone understands which patients will need the early discharge, nurses take charge of educating patients on what they will need to do when they return home.
“There is an end-of-the-day discussion to make sure there are no barriers to the early discharge,” Jacobs says. “In our system, the case managers are assigned by service, and the social workers are assigned by unit.”
So case managers have patients on six different units and cannot be at all final discussions. The social workers, who are part of the care management group, are there to discuss discharges with nurses.
5. Physicians give discharge medications to the pharmacy the day before discharge.
The pharmacy is part of the discharge discussion, so the pharmacy staff knows about these priority discharges.
Physicians write their medication prescriptions by 2 p.m. the day before the morning discharge, and this gives pharmacy staff enough time to prepare the medications by 8 a.m. the next day, Jacobs says.
“So after we identify the patient for an early discharge, we have a list made, talk about barriers, and get the medications ready,” she adds.
There was another efficiency change with pharmacy and prescriptions: “With the outpatient pharmacy, we found that certain discharge medications that providers were sending to the pharmacy prior to discharge were medicines that could be filled in the patient’s own pharmacy in the community, and the patient might prefer that,” Thielker says.
This highlighted the need for more robust communication between the care team and the patient to see how his or her medications should be filled. Although the discharge team assumed it was more convenient for patients to pick up their medications at the hospital, this was not true for some patients, he says.
Providers and care teams were educated to ask patients whether they wanted their medications filled at their home pharmacy. Complex medications could be filled at the health system pharmacy, which would have access to more of the complex drugs than would a community pharmacy.
The complex medications could be filled prior to discharge. The more common medications could be sent to the patient’s community pharmacy.
“We can get the pharmacy prescriptions for priority medications filled early,” Thielker says. “We’ve heard that this does reduce the volume of unnecessary medications being filled at the pharmacy. It’s a more appropriate use of pharmacy resources.”
6. Doctors complete the chart’s list of chief complaints or diagnoses.
Prior to discharge, physicians need to complete the patient’s chart. Depending on the clinical situation, the patient might suffer from hypertension, chronic obstructive pulmonary disease, or other conditions that need to be documented and updated.
“They prepare the discharge summary, do order reconciliation and medication reconciliation — all of the stuff the provider has to do to prepare the chart for discharge,” Thielker says.
This information tells the story of the patient’s inpatient stay, he notes.
“That’s a fundamental part of our process, and it falls under the banner category of things providers should be proactively trying to work on the day before discharge,” Thielker says.
The goal is to not wait until the morning of discharge — get the chart information updated the afternoon before discharge.
“They have to finish the things that need to be done for the next day,” Jacobs says.
7. Complete patient education the night before discharge.
“We ask the bedside nurses to complete all patient education the night before the discharge,” Jacobs says.
For example, a patient might need education about changing his or her wound dressing. The nursing staff will need to provide that education the night before discharge instead of in the morning of the discharge, Jacobs says.
“What we’re trying to do is make this change staffing-neutral,” she adds. “We tell everyone that it’s not more work because they’re always discharging patients anyhow, but the flow of work will be progressively in a different pattern — rather than heaping more work on them throughout the day.”
The nurse-patient ratios are the same for both morning and evenings, and the night nurses know how to provide patient education. The biggest change was to set the expectation of when the education should be provided.
8. Physicians write discharge orders by 9:30 a.m.
The usual pattern is that doctors would handle their surgical and other work early in the morning and write discharge orders in the afternoon. Now, physicians are asked to write the discharge order in the mornings.
This created a logistical conflict for some doctors. For instance, the medicine service might not have rounds until 8:30 a.m., and they will see their acute patients first. Acute patients are not the ones who will be discharged in the morning, Jacobs explains.
“So they have to let a resident skip rounding to do the discharge, or they can take the computer with them as they round,” she says.
9. Patients are discharged early.
Each unit discharges the early patients and confirms that they have exited the hospital. This information is collected for metrics about how well the early discharge program is working.