Extended-stay rounds can help move patients along
Team brainstorms on moving patients along
As an adjunct to daily multidisciplinary rounds to focus on what needs to be done for discharge, hold weekly extended-stay rounds and discuss any patients who have been in the hospital more than five days and what can be done to move them through the continuum, advises Peggy Rossi, BSN, MPA, CCM, a retired hospital case management director who now is a consultant for the Center for Case Management.
Multidisciplinary rounds should be held daily, and extended-stay rounds — also called complex care rounds or long-stay rounds — should be held once weekly, she recommends. "They both have the same basic purpose and end result — a mechanism to ensure that all is done to ensure a safe, smooth, and timely discharge," she says.
Many hospitals traditionally have held extended-stay rounds for patients who have been in the hospital 14 days or longer, Rossi points out. "But with average stays of three to four days, it’s a good idea to look at moving these patients along at five days," Rossi says.
Extended-stay rounds should be at the same location and the same time every week, she advises. The team should review patients with a stay of greater than five days and issues and barriers to the normal progression of care, she says.
Generally, the meeting should be scheduled for an hour to an hour and a half, with about five minutes dedicated to each patient, according to Rossi.
Participants should include the physician advisor for case management, the case management director, a financial counselor, and representatives from social work, case management, physical therapy, respiratory therapy, nutrition, wound care, pharmacy, and any other department that is providing services to the patients being discussed, she says. If home health liaisons and skilled nursing facility liaisons are assigned to the hospital, they also should be included, she adds.
"It’s important to include the medical director, who may need to call the attending physician about moving the patient along," she says.
Send a list of patients to be discussed to all participants before the meeting so each discipline can be prepared to discuss any issues or barriers they have encountered.
Rossi recommends that the case manager present the cases and compare the patients’ length of stay with the geometric length of stay and lead a discussion of what is extending the stay. Talk about the discharge plan and any alternatives, whether the patient has the resources to pay for the post-acute plan and, if not, what will be needed, and what barriers or issues should be corrected before the patient can move smoothly and safely to the next level of care.
One team member should take notes and place a summary of the team’s discussion and recommendations in each patient’s medical record. Team members should be assigned to address the barriers and report back to the team the next week.
Rossi cites examples of the types of patients that should be discussed during long-stay rounds:
• Cases in which there is a disagreement among the team members or family members about what needs to be done.
• Instances in which post-acute providers indicate that the care the patient requires is beyond their capabilities. This includes patients whose family has selected a post-acute provider that doesn’t have a bed available for the complexity of care required.
• Undocumented patients who will need a third-party payer and link to a provider for services after discharge.
• Patients whose insurer or third-party payer will not authorize the services needed or that the services are not available within the payer’s provider network. Rossi says the most common reason is that the payer will not authorize a discharge to a long-term acute care hospital (LTACH). "It boils down to contractual arrangements because many LTACH will not contract with an insurer or third-party payer and the LTACH’s daily rate is often much higher than the hospital’s reimbursement rate," she says.
• Patients with legal issues pending, such as guardianships or adoptions, or patients who are on an Adult Protective Services or Child Protective Services hold.
• Instances in which patients or families are undecided about discharge plans and drag their feet making a decision or change their minds at the last minute.
• Patients with psychiatric issues, including dementia. According to Rossi, patients with dementia often do not qualify for admission to a psychiatric hospital, and finding an appropriate facility can be time-consuming.