By Melinda Young

Long length-of-stay (LOS) patients can cost hospitals hundreds of thousands of dollars in unreimbursed care each year.

Hospital case managers can help reduce long LOS cases through consistent care management and team support, says Cynthia Smith, RN, BSN, CCM, nurse manager, department of case management, at Mid Coast-Parkview Health in Brunswick, ME.

One of the many obstacles to reducing LOS is finding a patients’ decision-maker, Smith notes. “You have a sick patient who does not have capacity to make a decision and who does not have a decision-maker,” she explains. Therefore, it is important to reach out to friends and family as early in the stay as possible.

Long LOS patients may be alone and cannot return home safely. Some of these patients lack decision-making capacity or are unable to take care of themselves in an independent environment, Smith says. “These are the most vulnerable people that live in the community,” she notes. “Some have mental illness, and some are elderly with very limited social supports and financial means.”

Long LOS patients also might experience behavioral and mental health issues. They might be violent or be agitated, and some potential referral facilities will not put their staff and patients at risk by taking in these patients. “We offer psychiatry to help with determining whether patients have capacity and to help with medication management when the patient has behavioral issues or violence,” Smith says. “They’re part of the team, as well.”

Some patients’ spouses are elderly and unable to provide care because of their own chronic illnesses or dementia. “We’re seeing more patients come to the hospital when their elderly spouse cannot care for them anymore,” Smith says.

When appropriate, providers can make referrals to hospice care or nursing facilities. But they need someone, whether the patient, spouse, or someone else, to be the patient’s decision-maker, she adds.

The lack of a decision-maker can affect the hospital’s ability to collect payment for its services. For example, the patient or decision-maker must be involved with the patient’s application for Medicaid or other payer resources. “It’s a complicated process,” Smith says. “You have to complete an application with years of financial documents and other things.”

Case managers can help by setting up a meeting with the patient and family or whomever might be important in the patient’s life. “We try to determine who the decision-maker is or who could be a decision-maker if the patient cannot be their own,” Smith says. “We initiate a family meeting within 48 hours to assess the level of care and to make appropriate referrals.” If patients have no one who can make medical decisions for them, then case managers can help the patient find a medical power of attorney.

After case managers help long LOS patients identify a decision-maker, the next step is to make appropriate referrals for the patients who do not have a medical reason for continued hospitalization.

“Realistically, we’re always going to have patients who have lengths of stay more than 30 days,” Smith says. “Our goal is to have fewer of these patients.”