Critical Path Network: Pilot admits patients from ED directly to post-acute care
Critical Path Network
Pilot admits patients from ED directly to post-acute care
Collaborative improves capacity and throughput
A collaborative effort between Boston's Massachusetts General Hospital emergency department staff and the health system's post-acute facilities and home care agency moves patients out of the ED and directly into post-acute care, freeing up beds and improving patient throughput.
During a 15-week pilot, 134 patients who presented in the ED and were appropriate for other venues of care were transferred to post-acute facilities directly from the ED, bypassing an acute inpatient hospital admission, says Laura Huber, RN, BSN, case management team manager.
The initiative was part of a systemwide collaborative effort by Partners Health Care to alleviate overcrowded conditions in the 907-bed tertiary care hospital's ED.
Partners Health Care is an integrated health care system that includes Massachusetts General and other hospitals; Partners Continuing Care, a group of post-acute facilities including a long-term acute care hospital (LTACH); an inpatient rehabilitation facility; a skilled nursing facility; and Partners Home Care.
A multidisciplinary team explored ways to move patients efficiently out of the ED and into post-acute care instead of admitting them as inpatients and then transferring them to post-acute care.
The team included the director of case management, who was the committee facilitator; members of the ED case management staff; the administrative physician in the ED; the senior director of referral relationships for the hospital's inpatient rehabilitation unit and long-term acute care hospital; the chief operating officer of Partners Home Care; the chief medical officers for the LTACH; the inpatient rehabilitation facility; and Huber.
"We collaborated to identify a population of patients we felt would be appropriate to go directly from the emergency department to inpatient rehabilitation or the LTACH. We obtained a commitment from the facilities to accept them directly and a commitment from our home care agency to have more availability of same-day visits," she says.
The team zeroed in on patients who were sick enough to require hospitalization but not sick enough for an acute care setting.
"If we could move these patients quickly out of the emergency department, we helped with capacity issues on the inpatient side by filling the beds with appropriate patients," Huber says.
Before the project began, senior leadership of Partners Continuing Care toured the ED and made recommendations as to how it could be part of the solution.
Working with the post-acute providers, the team determined targeted conditions for patients who should be assessed for a post-acute transfer and developed the following criteria:
- Patients who require acute diagnostic work-up such as interventional radiology, surgery, or ICU level of care continue to be admitted to the hospital.
- Patients who may be appropriate for a direct admission to an LTACH include those with chronic obstructive pulmonary disorder, congestive heart failure, pneumonia, falls with non-operable fractures and cellulitis as well as patients with Parkinson's disease and multiple sclerosis who need medication adjustments.
- Patients who are more stable than those who are admitted to an LTACH, who can't be discharged safely to home but require hospital level rehabilitation including medical management and nursing and can tolerate three hours of therapy a day are admitted directly to the inpatient rehabilitation facility.
- Patients who can't safely be discharged to home and have moderate nursing and medical needs and may require therapy can be admitted to the skilled nursing facility.
- Patients appropriate for discharge to home with home care are those who are medically stable enough to be managed at home, are cognitively functional, or have family or community support.
Case managers staff the ED from 8 a.m. to 9:30 p.m. Monday through Friday and on weekends from 8 a.m. to 6:30 p.m.
They round in the ED constantly, looking for patients who meet criteria for direct admission to continuing care facilities. They look at the admitting diagnosis, conduct an assessment, and make a decision about whether they feel the patient is appropriate for an inpatient admission.
Screening patients
A dedicated screener from Partners Continuing Care rounds with the case managers in the ED twice a day and is available by pager other times. She works with the case managers to identify patients for potential admission diversion and helps coordinate the referral and admission to post-acute care.
"We developed a close working relationship between the continuing care staff, the screening liaison, and our physicians to help them understand each other's needs, their capabilities, and their limitations," she says.
Clinicians often alert case managers of patients they're thinking of admitting to determine if they can go to post-acute care.
"The case managers have a high level of expertise and understanding of the levels of care. They know the capabilities of the post-acute facilities and if they will meet the needs of the patient," Huber says.
To facilitate timely transfer and expedite throughput, the hospital's therapy staff make assessment of ED patients their highest priority.
The ED case managers educated the physician staff about how the program would work and which patients would be appropriate for direct admission to other facilities to get their buy-in before the initiative started.
"If they aren't comfortable with admitting the patient directly to post-acute care, the case manager has them talk to the chief medical officer of the LTACH or the rehabilitation facility. Physician-to-physician discussions are very effective," Huber says.
If patients are transferred from another facility, the ED physicians are encouraged to talk to the medical director at the transferring facility to see if care can be provided there.
During the pilot study, 68 patients were referred to Partners Home Care, 54 patients were referred and accepted by Partners Continuing Care post-acute facilities, and nine were referred and accepted by facilities not affiliated with the hospital. Two patients were admitted to Partners Hospice.
A few patients who were appropriate for other venues of care were admitted as inpatients, either because their primary care physician insisted on it or the patient refused to go to another facility, Huber says.
The hospital's "Tiger Team," a team of high-level executives, created the pilot project and appointed a multidisciplinary "Cub Team" to carry it out.
The term "Tiger Team" originated with the military and describes a team whose role it is to penetrate friendly installations and check their security measures. At Massachusetts General, the "Tiger Team" includes the CEO, the senior vice president for patient care services, the chief of surgery, the chief of medicine, the chief medical officer of the hospital, and the president of the Massachusetts General physician's organization.
(For more information contact Laura Huber, RN, BSN, case management team manager, Massachusetts General Hospital; e-mail: [email protected].)
A collaborative effort between Boston's Massachusetts General Hospital emergency department staff and the health system's post-acute facilities and home care agency moves patients out of the ED and directly into post-acute care, freeing up beds and improving patient throughput.Subscribe Now for Access
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