Access Management Quarterly: LOS reduced as system hones case management

Bed management, discharge initiatives cited

It’s been more than a decade since Lehigh Valley Hospital and Health Network in Allentown, PA, took its discharge planning and utilization management functions and created a resource utilization department with a single director, says Susan Lawrence, MS, CPHQ, administrator of quality and case management.

The "forward thinking" exemplified by that move — unusual for its time — continues to the present, she adds, paying off in continually decreasing lengths of stay (LOS) for the 750-bed system, which includes two hospital campuses in Allentown and another in Bethlehem.

Such present-day initiatives as daily bed alerts, emergency department (ED) case management, and an express admit unit for direct admits from physician offices continue to streamline health system operations, Lawrence explains.

Medicare patients at Lehigh Valley have an average LOS of 5.3 days, she notes, while the average medical-surgical LOS is 4.5 days. The latter figure becomes more impressive, Lawrence points out, when you consider that it includes level-one trauma patients, and those in the neonatal intensive care (NICU) and burn units. Babies in the NICU, she adds, can have stays of from 20-40 days.

After the creation of the consolidated department in 1990 — now known as the case management department — the next pivotal move, Lawrence says, was the decision in 1994 to combine the roles of the discharge planner and utilization management (UM) nurse, so that each could perform the other’s duties.

"We were implementing patient-centered care, and we began looking internally at how we could adopt some of those principles and have less people interacting with the patient and the medical records," Lawrence says. "We looked at the job descriptions of the discharge planner and the UM nurse, and thought we could put those roles together completely."

The department conducted a three-month pilot, with two discharge planners and one utilization nurse performing the blended function. The findings, she says, were that the discharge planners were able to review the medical record, assess severity of illness and intensity of service, evaluate the clinical information, and report all that to the insurance company to get authorization.

Conversely, Lawrence says, the UM nurse was able to assess patient needs at the time of discharge and develop plans for post-hospital care, whatever those might be. "It took about 12 months to cross-train everyone, so it was the end of 1995 by the time that was fully implemented," she notes. "We began to see some improvements in LOS, and we did not see an increase in denials."

With the combining of the two functions, Lawrence adds, the person handling the case is "constantly aware of whether the patient meets the criteria to be in the hospital and can immediately act to implement the plan. You’re not repeating, so you save time."

The health system has used that model ever since, she notes, and in 1999, began an additional focus on decreasing LOS. "We tried to refine the role of case manager and increased the recognition of that role throughout the organization."

With LOS reduction identified as an important priority, Lawrence says, the health system began holding weekly multidisciplinary meetings, pulling in representatives from such areas as respiratory therapy, pharmacy, and radiology. "We were able to bring to the surface what some of the delays were."

In response to those findings, she notes, the health system implemented Saturday thallium stress testing and weekend physical therapy, among other changes.

"We have also done some studies to evaluate what’s affecting LOS, and we’ve identified a lack of short-term skilled nursing facility (SNF) beds," Lawrence says. "We happen to have a hospital-based SNF unit, but it was only staffed for 32 beds. Once we demonstrated the need, it was opened up to 42 beds. It’s licensed for 55, so the data are evaluated periodically to see if we need to recruit more staff to open more beds."

Daily bed alerts instituted

Because Lehigh Valley’s registration process is fairly decentralized, there is no admitting department, Lawrence explains. Direct admits are sent from the front door to the nursing floor, and staff there perform registrations, she adds. ED registrars report directly to the ED management, Lawrence notes, and there is a person with the title of director of support services who supervises registrars in certain areas.

The director of bed management — a function that, in many hospitals, is part of access services — handles one of Lehigh Valley’s LOS initiatives, she says. That individual, who supervises a department that is staffed 24 hours a day, seven days a week, issues daily bed alerts when the hospital gets to certain occupancy levels.

"They will send pages, messages out to various members of the staff, including case managers," Lawrence says. "What that tells us is how many people are awaiting beds and what kind of beds they need. It helps the staff to prioritize."

Like many other providers, Lehigh Valley has looked closely at ED operations in its efforts to relieve overcrowding and increase bed capacity, she notes.

Case management in the ED was instituted after a pilot program showed that it avoided a significant number of inappropriate admissions, Lawrence says. The ED case manager is able to arrange SNF admissions for non-Medicare patients directly from the ED, she adds. "Even the placement of Medicare patients can be facilitated if they don’t need acute care."

The ED case manager also has helped a great deal in placing patients in assisted-living homes, setting up home care, and ordering durable medical equipment, Lawrence adds. "[The case manager] has been a really good resource."

A project called Clockwork ED "implemented a lot of processes to improve ED efficiencies, but we realized that many of our inpatient operations were impacting [the ED’s] ability to send patients to the floor, she says. "If a patient is not discharged from the bed, [another patient] can’t move up from the ED," Lawrence adds, "so we created a large group called Growing Organizational Occupancy,’ which we call GOC."

That team, which began meeting in October 2002, has chartered a number of subgroups, she says, to focus on various parts of the hospitalization process.

The team’s first mission was to look at the mechanics of discharge, Lawrence notes. "If you’re being discharged and going home with your family, how do we get you to the front door?"

"Then we had a group that looked at how to get a bed cleaned as quickly as possible," she says. "We identified that the patient may have left the building, but we were unable to turn around [the room] quickly enough. Part of it is the nurses are busy with other patients, and cleaning the bed is not a top priority."

A number of recommendations have been made to streamline the process, she notes, including a proposal for automating discharge paperwork. Under this plan, Lawrence explains, physicians would generate orders on the eve of discharge that would notify physical therapy, radiology, and other pertinent areas to move toward getting the patient out by 11 a.m.

"We’re trying to increase the percentage [of early discharges] from 8% to 20%," she says. "To make that happen, we’re working on a communication campaign targeting patients’ families, all caregivers. We want to communicate a consistent message that — like a hotel — once you’re discharged, it’s time to go."

The idea, Lawrence says, is to eliminate such scenarios as telling a patient at 9 a.m. that she’s been discharged and having her say, "I’ll call my husband and have him pick me up. He gets off at 4 p.m."

"It’s about changing everyone’s mindset — informing patients that as soon as they’re discharged, our goal is to make the bed available for the next patient," she says.

Another plan has to do with establishing centralized dispatch for external transport, Lawrence says. At present, individual case managers call various ambulance companies to secure arrangements for their patients, she notes. "We’re proposing they call a central number and have [a dispatcher] call and make arrangements."

Although case managers still would be making the same number of calls, Lawrence says, this method gives the hospital more control over the time that a patient is being picked up and allows prioritizing.

"If we need an ICU [intensive care unit] bed more quickly," she adds, "we could prioritize an ICU transfer out earlier in the day. If case managers are making arrangements independently, they’re all vying for the same time."