By Jeanie Davis

As urban hospitals grapple with length of stay (LOS) penalties, they must help their patients solve everyday problems. Lack of resources is a fact of life for inner city residents, and hospitals need to find a way to help those patients overcome those obstacles — and reduce LOS.

In 2019, Vitrea Singleton, RN, MSN, CCM, joined South Pointe Hospital, an urban hospital on the edge of Cleveland, as the manager of care management — and inherited the hospital’s LOS problems. Some issues were internal, involving delays in hospital processes. Others were inherent in an underserved population. “Some patients stay extra days because their caregiver can’t get off work, they can’t get a ride, or they didn’t have anyone to help with home care,” she says. “We constantly dealt with those types of challenges.”

The hospital nurses and social workers held daily meetings to plan patient discharges. However, Singleton found that C-suite support could be helpful in “pulling strings” to get patients the help they needed.

She initiated a plan to transform the daily meetings, turning them into strategy sessions with the goal “to enhance patient experience, achieve the best patient outcomes, and reduce overall healthcare costs,” she explains.

The case management team includes Singleton, eight nurses, and six social workers. In August, they conducted a hospitalwide needs assessment to identify processes to reduce LOS.

First, the team improved the patient intake process, using a comprehensive assessment form that helped better identify the patient’s needs and potential barriers in discharge planning. “Learning the barriers very early helps us get ahead of the problems and address them,” she says.

The team also identified key points that affected LOS. This primarily involved delays in insurance approvals, scheduling, and patient transportation. They found that patients hospitalized for observation were held up to 40 hours (the goal is now 30 hours) because of scheduling delays for diagnostic and surgical procedures.

The daily team meetings have evolved over time, Singleton reports. “They have become more in-depth every time, a more collaborative effort, and the executive team has become much more involved,” she explains. “I think they’ve learned the process is not as easy as it looks. They’ve gotten involved in handling certain barriers, and prioritizing changes to improve scheduling and insurance approvals.”

The executive team also has pulled strings to find subsidized home care for patients, a significant move in reducing LOS. Whereas LOS has been reduced to 4.5 days, she expects the hospital to reach its 4.2 goal by January. “We keep hammering away at the goal,” she says.

Because the initial patient assessment is comprehensive, the team anticipates the patient’s needs long before discharge, Singleton adds. “We also anticipate the barriers and risks, and develop Plan A, Plan B, and Plan C accordingly.”

This early planning allows the team to obtain insurance approvals and make early referrals on the patient’s behalf; for example, to identify the viable home care options. Adding a nurse practitioner to assist with discharge planning has helped solidify the plan and prevent readmissions, she adds.

These improvements “will help the hospital avoid CMS penalties and achieve a competitive advantage, able to attract improved technology and high-quality healthcare providers,” says Singleton.

Singleton believes that a case manager is most effective in a management position, as this brings greater access to the C-suite — which helps get things done. She advises nurses to pursue a master’s degree to improve their leverage in their hospital system.

Singleton has adopted the role of project manager with the discharge planning team to focus members on identifying problems, then setting and achieving goals toward improvement. “We want to be a model of achievement in our hospital,” she says. “We want to show others that changes can be made fairly quickly and effectively.”

Toni Cesta, PhD, RN, FAAN, partner and consultant with Case Management Concepts, LLC, puts this in perspective: “Managing length of stay is a multifactorial process that includes internal hospital delays as well as delays outside the walls of the hospital,” she says. “Some of these delays are correctable if identified and dealt with early.”

Identifying patterns of delay, rather than using each delay as a one-off, is most important, she adds. Typically, the categories include internal system delays, external system delays, patient, family, legal, provider, and others.

“Case managers have an obligation to perform three functions as it relates to avoidable delays,” explains Cesta. “First, identify them in real time. Secondly, work to correct them in real time. Finally, enter them into a database so that patterns and trends can be identified for corrective action.”

An interdisciplinary team often is key to reducing occurrence rate, so choose those delays that provide the biggest return, she adds.

Also critical: identifying those delays that are most easily correctable. “This is a key role for hospital case managers, but sometimes underperformed due to staffing or other time constraints.”

Avoidable delay management should be part of the case manager’s daily workflow, Cesta explains. This will foster a more comprehensive approach to LOS management as it focuses beyond discharge planning delays.

“As your department begins to chip away at these delays, the overall throughput of your patients will be improved, and LOS will improve as well,” she adds.