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Patient flow initiatives decrease LOS, up capacity
Daily, weekly meetings address throughput
By implementing a series of patient flow initiatives over a 10-month period, UC Health University Hospital, a 693-bed academic medical center in Cincinnati, was able to decrease the average patient length of stay by 5.34 hours, giving the hospital the ability to serve 1,300 more patients each year.
Before the project began, the hospital reorganized its care coordination efforts: creating a triad model in which case managers, social workers, and quality management nurses work as a team; collaborating on the best discharge plan for the patient; establishing what funding is available for post-acute needs; and moving patients through the continuum as quickly as possible.
At the time the project began, the hospital had home care coordinators who were responsible for discharge planning for patients who needed home care. Social workers handled placement in post-acute facilities, and the quality management nurses were in charge of utilization review.
The redesign expanded the role of the home care coordinators and created the role of case manager, whose duties include facilitating throughput by assuring that patients get the care they need in a timely manner as well as setting up home care referrals.
"We were working with a consulting firm to improve our patient flow housewide. They recommended redesigning the department. They told us that we needed somebody to be on the unit every day consistently to make sure that the patients were moving through the system efficiently, says Ginny Warner, RN, BSN, ACM, manager of case management.
At UC Health University Hospital, case managers are assigned by unit and typically have a caseload of between 24 and 43 patients, depending on the acuity of their patients.
"Case managers in the ICU can usually carry a heavier load because, while they transition patients through the system, they aren't spending hours lining up resources for patients who are going home," says Peggy Sogar, LSW, division director over service excellence, case management, social work, patient relations, volunteer services, and spiritual care services. UC Health University Hospital is a Level 1 trauma center and an inner-city, safety-net hospital.
Many of the patients are seriously ill or have been catastrophically injured and have complex psychosocial issues, Warner says.
"Our case manager and social workers are creating discharge plans for many patients whose psychosocial needs impede a quick and efficient discharge. The patients may be medically ready to go home, but because of their psychosocial issues, it may take a while to set up all of the resources they need for a safe discharge," she says.
In addition, the hospital is in a tri-state area and treats patients from Kentucky and Indiana who also have complex medical and psychosocial needs. Finding placement for them in their home state if they don't have funding or finding post-acute services in Ohio when they are residents of another state is also a challenge, Warner adds.
Working with Wellspring + Stockamp HuronHealthcare, a Chicago-based consulting firm, the hospital developed daily and weekly meetings during which staff analyze patient throughput issues and brainstorm ways to alleviate roadblocks, Sogar says.
Each unit in the hospital holds daily care coordination rounds facilitated by the charge nurse and attended by the case manager, the social workers, bedside nurse, and as many other disciplines as possible.
The team looks at each patient on the unit, discusses the plan of care, the anticipated discharge date, patient transportation, discharge medications, and other discharge needs.
"We look every day to see how the patient is moving through the system and intervene to remove any roadblocks to a timely discharge," Sogar says.
For instance, if a patient is scheduled for a test that would determine if he or she is ready for discharge, the case manager makes sure it is scheduled early in the day.
The entire case management and social work team attends a clinical high-risk meeting once a week to discuss patients at high risk for a lengthy stay.
"We started looking at patients with a stay of eight days or greater, but as we have gotten more experience, we have been able to identify difficult discharge situations more quickly," Sogar says.
For instance, if the patient is from another state and doesn't have insurance, finding a post-acute placement could be a problem.
The vice president of finance, the vice president of operations, and the vice president of medical affairs attend the high-risk meetings and deal with any issues or concerns with their area of the hospital.
During weekly patient progression meetings, the directors of every nursing unit, the case management manager, the social work manager, and representatives from admitting, the bed board office, and transportation analyze performance indicators to determine if each department has met its goals.
For instance, case management tracks the cases that are reviewed within one business day, avoidable days, patients who could have been discharged if there hadn't been an avoidable day, cases with a discharge barrier, and whether the barrier was internal or external.
"During our three years of case management, we have attacked and resolved a lot of internal system issues, and now we rarely have internal avoidable days. Most are external and have to do with payer issues," Warner says.
Social work tracks the number of cases that need highly complex discharge planning, transportation to other facilities, and barriers to a speedy discharge, such as a hold-up in pre-certifications from insurance companies.
In addition to the meetings, the case management team has been working in other areas to remove roadblocks to discharge, Sogar says.
For instance, the case managers have worked to involve physicians in the throughput process. If the physicians can't attend the daily care coordination rounds, the case managers go with them on early morning rounds whenever possible and report back to the care coordination team.
"This is sometimes difficult because physicians have patients on multiple units. If the case managers can't attend the morning rounds, they text-page the physicians and ask them to call with an update. It makes it easy to get a quick response because the physicians know what information the case manager needs," Warner says.
The team has developed an escalation process in which the frontline staff (case managers or social workers) refer problems they have not been able to solve to their manager, who in turn engages Sogar when necessary. Sogar can call on a hospital vice president if she needs assistance in taking care of the problem.
Case managers and social workers track avoidable days and look for trends, then work to find ways to change processes to improve patient flow.
"We can use the data to show the value of case management by tracking the days the case managers and social workers have saved by getting the patients out quicker and saving the hospital money," Sogar says.
Since the care coordination rounds began, the hospital has experienced a 40% increase in accuracy of predicting next-day discharges from the medical/surgical units. Some units have achieved greater than 50% accuracy.
The team is still challenged by the fact that many patients have complex medical conditions and often experience setbacks in recovery. In addition, since UC Health University Hospital is a teaching facility, both the resident and the attending physician have to be on board for discharges.
"All of this plays into whether or not we can accurately predict discharges. We have been slowly increasing that metric but giving an extra focus in the care coordination rounds on when the discharge is going to happen so we can have everything needed lined up and in place," Sogar says.
(For more information, contact: Peggy Sogar, LSW, division director over service excellence, case management, social work, patient relations, volunteer services, and spiritual care services, UC Health University Hospital, e-mail: Peggy.Sogar@healthall.com.)