Critical Path Network

Focusing on appropriate levels of care, hospital lowers length of stay

Initiatives include a fund for meeting discharge needs

When California Pacific Medical Center was named a top hospital for patient quality and safety for the fourth year in a row by the Leapfrog Group, the award cited the hospital's length-of-stay initiatives.

"We get a report on length of stay twice every week, but we take an old-fashioned approach to length of stay. We don't work on reducing the statistics. We work on providing quality patient care and putting processes in place to support moving patients to the most appropriate level of care environment," says Mary Kay Simmons, manager of outcomes management for the San Francisco medical center.

California Pacific Medical Center, a Sutter Health affiliate, has four campuses — the Pacific Campus, a tertiary care hospital; the Davis Campus, which includes an acute care hospital and a skilled nursing facility unit; the California Street campus, which provides mainly mother and child care, orthopedic surgeries, and has a skilled nursing unit; and the St. Luke's campus, which has a community hospital focus with a skilled nursing facility and a subacute unit.

Case managers are assigned differently on each campus, but all are responsible for 20 to 22 patients a day. They conduct an initial screening within 24 hours of admission to determine if patients are likely to have discharge needs and identify those patients in the medical record.

Patients who are likely to need discharge planning are those who are over 65 and/or who have joint Medicare/MediCal benefits, patients who are under 65 and who have chronic conditions and/or multiple cormorbidities, and patients with no insurance who have complex medical needs.

On each campus, the case management team meets at least once a week with the medical advisor to review Medicare patients who are hospitalized for four days or more for medical necessity. The team also discusses patients who have complicated hospital stays and may need extra focus on what is needed to move them safely to the next level of care.

"Our vice president of medical affairs, our chief of medicine, and the physician advisors on each campus are very active in our length-of-stay meetings. One of them comes to each of the meetings. In addition, we have a great hospitalist group that works very closely with us. In the meetings, we talk about the stumbling blocks to discharging the patient and what, if anything, we can do to change this," she says.

California Pacific Medical Center has instituted several initiatives to ensure that patients move to the next level of care as soon as possible when they no longer meet acute care criteria.

Among the initiatives are instituting a transfer-back agreement with area hospitals that transfer patients to CPMC for specialized care and evaluation; developing a community fund that is used to provide post-discharge needs for patients whose insurance doesn't cover it and who can't afford to pay for specific items or care; and establishing a custodial unit where patients who have no family and can't take care of themselves can stay while the state establishes a guardianship.

Because California Pacific Medical Center is a tertiary care hospital and a regional transfer center for Sutter Health and Northern California, the medical center receives a lot of patients who are transferred from other hospitals for organ transplant evaluations, heart or stroke procedures, and complicated medical work-ups.

Transfer-back agreement

The hospital has developed a transfer-back agreement with the transferring hospitals that requires them to take patients back after they have received the specialized care or evaluations they need.

The case managers alert the transferring hospitals 48 hours before the patients are ready to be transferred back.

"Our case management department puts a lot of time and energy into transferring people back to the outlying hospitals as quickly as possible so the patients can be near their families and to free up beds and keep our length of stay as low as possible," she says.

When patients are staying in the hospital because of post-discharge needs and social issues, the case managers and social workers can access funds to help pay for whatever it takes to safely discharge the patient.

"Sometimes we aren't able to discharge patients because they need a special wheelchair and their MediCal benefits haven't come through. We can tap into the fund to get the wheelchair and get them discharged safely and quickly," she says.

Case managers can use the funds to provide home care services for patients who don't have the benefit if the alternative is keeping them in acute care longer.

If patients are staying in the hospital because they can't afford medication or IV treatment in the home, staff work with the pharmaceutical companies to donate medications so the patient can go home.

"We have a great working relationship with the visiting nurses and hospice care staff and work collaboratively with them to refer patients to them. They are able to take our referral quickly, which again allows for a safe and timely discharge," she says.

Faced with a growing number of patients who aren't capable of caring for themselves and/or making their own health care decisions and who have no family to make the decisions or provide care, the hospital looked for ways to ensure that the patients are safe and cared for while the process of establishing a conservatorship and MedCal coverage for the patient is taking place.

The process can take as long as two to three months, during which time the patient cannot be safely discharged to the community.

The hospital established a custodial care unit at the St. Luke's campus where patients who are not competent to care for themselves can receive the supervision and the medical and nursing care they need until the conservatorship papers are completed and the state takes over the responsibility for the patient.

Patients who no longer need acute care or skilled nursing care are transferred to the custodial unit. Most are eventually discharged to a MediCal bed in a long-term care facility.

"We never discharge anyone unless we know they will be able to manage on their own and be safe. We look at all kinds of creative ways to get patients what they need in the next level of care, but we emphasize to the case managers that we never discharge a patient unless it is safe," Simmons says.

(For more information, contact: Mary Kay Simmons, Manager of Outcomes Management, California Pacific Medical Center, e-mail: simmonmk@sutterhealth.org.)