Discharge Planning Quarterly

Pre-admission prediction tool improves process

Idea is to gain patient buy-in

Sometimes the best response to regulatory and payer changes in health care is to improve the discharge planning process.

And sometimes the best way to improve the discharge planning process is to start discharge planning before the patient is admitted to the health care facility.

This essentially is what happened when a team of leaders looked at the industry changes occurring in orthopedic surgery discharges and post-surgery rehabilitation and realized that something major would need to be done.

A clinical performance management team at Massachusetts General Hospital in Boston closely examined orthopedic surgery costs, length of stay (LOS), process improvement, and Medicare regulatory changes, says Pamela J. Tobichuk, RN, ONC, a nurse case manager with the pre-admission orthopaedic total joint program. Tobichuk spoke about using a pre-admission prediction tool to improve the discharge process at the 18th annual conference of the Case Management Society of America.

"Most of our population wouldn't be able to go to an inpatient rehabilitation facility," she says. "The majority would need to go home or to skilled nursing facilities, which was a huge difference in what they were used to."

The regulatory and payer changes meant too many issues would need to be resolved: First, patients might have expectations that could not be met, and secondly, the hospital's LOS for these patients might increase as a result of fewer viable discharge options.

"We wanted to be proactive and see how we could maintain our good LOS, if not decrease it, and yet manage patients' expectations around what they'd be doing after surgery," Tobichuk says.

One member of the clinical performance management team came across a risk assessment tool that looked useful. It was described in a 2003 issue of the Journal of Arthroplasty, in an article, titled, "Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty."

"We took this tool back to the team and said, 'How can we use this as a starting point for our program?'" Tobichuk says. "And that's where the development and implementation began."

After receiving permission to use the tool, the team adapted it for their own use, primarily by changing words to work better for an American population. The tool had been used in Australia, she notes.

The resulting six questions are scored with two- or three-point answers, meaning the patient is at the lowest risk, and one- or zero-point answers, meaning the patient is at the highest risk, Tobichuk says.

She calls patients prior to their surgery to ask them the tool's questions. As patients give answers, Tobichuk assesses their risk and discusses their post-discharge options, asking them, "Do you have a plan or preference for your discharge?"

Here are the tool's questions:

  • What is your age?
  • What is your gender?
  • How far on average can you walk?
  • What do you currently use to help you walk?
  • Do you currently have any help from the community?
  • Will someone be living with you who can care for you after your operation?

There is a maximum of 12 points. Anyone who scores greater than nine points is at the lowest risk for needing to be transitioned to a skilled nursing facility, Tobichuk says.

"If someone scores 10-12 points, then let's have that person go home," she adds.

At the other end of the spectrum, if a patient's score is fewer than six points, then that patient is at a high risk, she says.

"We would predict that patient would have to go to a skilled nursing facility for nursing rehabilitation," Tobichuk says.

Patients whose scores fall in the middle category of six to nine have moderate risk, and their discharge outcome is unpredictable, she adds.

"They either could go home with a visiting nurse or be transferred to a skilled nursing facility," Tobichuk explains. "If someone scores in the middle range and their preference is to go home, then that might be someone who could benefit from more physical therapy in the hospital to help them get over the hump, and we might send them home with more support."

When using the tool to assist with discharge planning, it's important to consider the patient's general motivation to work at rehabilitation in whichever setting the patient might prefer.

A patient who scores at low risk and who is highly motivated might not need home care services, but could go directly to outpatient physical therapy after being discharged from the hospital, Tobichuk says.