Discharge plan reduces LOS for long-stay patients

Planning starts early after admission

In the first year of Stony Brook University (NY)Medical Center care management department's interdisciplinary project to reduce the length of stay for long-stay patients, aggregate patients days dropped from 4,400 to just more than 3,000 in a year, resulting in a revenue opportunity of approximately $4 million.

Now the care management team at the 571-bed hospital has narrowed its focus to patients who stay 10 days or more with a goal of eventually including patients who have been in the hospital seven days.

"We started by focusing on patients here 30 days or more but identified that there are many opportunities to move patients forward before 30 days. We are continuing to fine-tune our actions and focus on moving patients safely through the continuum. Many times, the biggest opportunity for decreasing the length of stay occurs around seven days," says Catherine Morris, RN, MS, CCM, executive director for care management.

Reducing LOS

The longer patients are in the hospital, the more they are at risk for infection, pressure ulcers, and the deconditioning that occurs when they are bedridden, Morris points out.

The hospital began a strategic initiative four years ago to reduce the length of stay for long-stay patients and established a team to analyze processes and implement improvements in the discharge process.

As a tertiary care hospital and the only Level 1 trauma center in the county, Stony Brook Medical Center treats patients whose needs can't be met at other hospitals in the area, including patients with severe injuries and those who are clinically acute.

"These patients typically have long lengths of stay, and their discharge needs often are quite complicated. Our long length of stay team is working to move patients to another level of care as quickly and safely as possible and open up the bed for another patient who needs the kind of services we provide," Morris says.

The long length of stay committee comprises an administrative-level meeting that includes the case management director, the social work director, the admitting department's Medicaid liaison, the physician advisor, and representatives from finance, patient access, managed care, nursing, and legal services, which in the case of Stony Brook is the New York State attorney general's office since it is a public hospital.

The team meets on a weekly basis, reviews the cases of long-stay patients, and determines what can be done to move patients safely through the continuum. It provides administrative support to the clinical team.

"We keep moving the focus to a lower length of stay so that patients are clearly looked at from a multidisciplinary viewpoint as early in the hospital stay as possible," Morris says.

Knowing your patients

Each week, each clinical team member receives a spreadsheet listing all long-stay patients. The list includes the length of time in the hospital, the unit the patient is on, the clinical staff on the unit caring for the patient, the physicians involved, the payer source, and the current hospital charges.

Before the long length of stay meeting, the directors of the care management department meet with the clinicians who are actually providing the care and coordination for each patient and gather pertinent information that is added to the record.

In the meeting, the team develops an action plan and assigns responsibility for each element to a team member who follows up the next week.

"If the patient is self-pay, we make sure his or her Medicaid application is in place. If we are working with a managed care organization, we may negotiate with them for benefits. We work on getting disability set up and assist families in making decisions regarding hospice or terminal care," Morris says.

In one case, the patient was close to her lifetime benefit limit. The long length of stay committee negotiated to adjust the hospital bill so the patient would have benefits left for post-acute care.

"Discharge planning starts on the first day, but for these patients, the ultimate plan is to start looking at patients administratively at seven days, even though they are not clinically ready for discharge. If we start early, it helps us move the patients forward at the end of the stay," Morris says.

For instance, the hospital treated an uninsured patient from Mexico who was in the United States on a work visa and was hit by a car, receiving injuries that left him a quadriplegic. He had no family in the United States and his family in Mexico wanted him to come home so they could care for him.

"We knew he would need a hospital bed in his home in Mexico and the right kind of wheelchair. We started early in the stay to work with the insurance company of the person who hit him and to coordinate what he would need after discharge. If we had waited until he was ready for discharge, it would have added several more weeks to his stay," Morris says.

The long-stay committee pulls in other hospital staff when needed to facilitate moving a patient to a more appropriate level of care.

The nurse managers on the unit are invited to the long length of stay rounds to provide a different perspective of what the patient may need.

"The nursing staff give us very specific information on the patient's condition and how to meet his or her discharge needs that could be overlooked when there isn't good communication among all members of the team," Morris says.

For instance, when the team was discussing transporting the patient back to Mexico, the team looked for ways to deal with the patient's incontinence during the five-hour plane ride and two-hour car trip to his home.

"We were discussing providing a particular type of catheter, but the nurse pointed out that it wouldn't work for him so we had to find other options," Morris says.

The long length of stay team got the hospital's physical therapy staff involved in a special project for the patient returning to Mexico. Along with the care management staff, they produced a DVD demonstrating the exercises and range-of-motion activities the patient should do, had it translated into Spanish, and sent it with him for use by his family.

One goal of the long-stay initiative is to improve communication between members of the multidisciplinary treatment team throughout the hospital, including establishing regular rounds with nursing, the physician staff, social workers, case managers, and other pertinent disciplines participating on each unit.

"Often, the treatment team members work in silos. The doctor is very interested in the patient's medical care. Nursing handles their piece, and the case managers and social workers focus on the discharge piece. Communication across all the disciplines is critical to making sure that the patient moves forward through the continuum and receives the post-hospital care he or she needs," Morris adds.

Communication with the patient and family also is an important part of ensuring that the patient moves through the continuum, she says.

"Our hospital's model is patient- and family-centered care, so we want to make sure the family and patients are aware of what is going on with the clinical care and have a chance to give their input. If they know what kind of care the patient is going to need after discharge, it gives them a chance to plan in advance and makes the process smoother," Morris says.

Anticipate holdups

In order to systematically identify and track organizational and process impediments to throughput, the team has developed a comprehensive list of barriers to discharge with codes that identify the reason the discharge was delayed. For instance, reasons include no skilled nursing bed available, no ventilator bed available, the patient needs a guardianship, there is no payer source, and holdups in paperwork.

"In the long run, because we are using these codes, we can classify patients and identify the major barriers to discharge and develop target interventions. We can also calculate costs associated with these barriers and delays. High-level strategic initiatives may be put into action based on certain trends," Morris says.

Already the hospital is working to develop partnerships with local nursing facilities and dialysis centers to make sure patients can receive the services they need when they no longer meet criteria for acute care.

"One delay trend we identified was that Medicaid applications were taking an extended length of time to process. We worked with the local department of social services to place an employee on site to help speed up the process," Morris says.

The long length of stay team is working with the state attorney general's office to speed up issuing guardianships for patients who can't make decisions for themselves and have no available next of kin.

"We have arranged with durable medical equipment vendors for quicker service and are working with local skilled nursing facilities on a project to possibly rent beds from them. If the only way to get a patient out of the hospital is for the hospital to pay for a post-acute bed, we may have to do so but only if the rate is cost-effective," Morris says.

The hospital has organized special funds to facilitate moving uninsured or underinsured patients to the next level of care as quickly and safely as possible when they no longer need acute care, opening up beds for patients who require acute care.

The special discharges fund pays for some of the post-acute needs for patients who are unable to pay, such as providing transportation back and forth for radiation treatment, special formula and feeding apparatuses, or paying for a wheelchair.

In one instance, when the hospital was trying to place a quadriplegic patient, the team negotiated an arrangement with a local nursing home to provide the subacute care if the hospital would meet the patient's follow-up acute care needs and was able to get a wheelchair for the patient donated.

The medication assistance fund helps provide assistance with certain medication needs after discharge.

The hospital also has an indigent patient fund, supported by donations and fundraising projects, that provides money for an array of services, car seats for newborns, food, clothing, shoes, and transportation for patients who can't afford it.

"Managing the long length of stay population continues to be challenging. Although the trend continues in a downward direction, these patients continue to account for 10.7% of our discharges. Hospital throughput projects focus on streamlining the process and removing system barriers. The care management department continues to spearhead individualized and creative approaches to providing patients with the services they need at the right level of care. We just have to keep thinking out of the box," Morris says.

(For more information contact: Catherine Morris, RN, MS, CCM, Executive Director for Care Management, Stony Brook Medical Center, e-mail: catherine.morris@stonybrook.edu.)