Discharge initiatives help transition patients through continuum of care

Pre-discharge form sets wheels in motion

A pre-discharge order form and an 11 a.m. target time for discharging patients are among the initiatives the care management teams at the Medical University of South Carolina (MUSC) in Charleston have created to help move patients through the continuum of care more efficiently. The 596-bed tertiary care center serves as a resource for the entire state of South Carolina.

"Some physicians feel that patient access to the hospital is difficult. We are full a lot, and patient flow is a big concern. We need to move people through the system efficiently so other patients can have access to tertiary care resources," says Lynne S. Nemeth, RN, MS, director of care management, research, and evaluation at the medical center.

Discharge planning has become more difficult as the hospital treats sicker patients whose conditions make it harder to predict when they’ll be ready for discharge. "Our length of stay has been truncated by capacity needs and access needs. As a result, we might have kept patients longer in the past, but now we need to move them through the system quicker," she says.

The hospital administration appointed 27 different task forces in December to look at patient capacity and come up with new ways to move the patients more efficiently through the continuum while providing more effective care. "We’re looking at all kinds of options that allow us to creatively move patients through the continuum in a timely manner," Nemeth says.

But Nemeth and her team have been tackling the issue for several years, working closely with the hospital’s physician staff to improve the discharge process and have succeeded in significantly reducing the number of avoidable days by working proactively with the physicians.

One challenge the team faces is the fact that MUSC is an academic medical center and many physicians conduct both teaching rounds and patient care rounds, often at intervals throughout the day. "It’s sometimes a struggle to coordinate with the physicians because of competing demands of the teaching physicians," Nemeth says. "They have an academic mission, and we need efficient decision making and orders. We’re trying to work with them."

The case management staff are working with the physicians to have all discharges effective at 11 a.m. "Our preference is for the patients to be discharged in the morning so we can admit those scheduled for today," she says.

Some physicians have mentioned that a rule mandating an 11 a.m. discharge could be ineffective because if physicians’ schedules keep them from seeing patients until the afternoon, those patients have the potential of staying another day. "We’re working with the physicians to have ongoing communication about the patients’ needs so we can facilitate the discharge," Nemeth says.

To ensure that everyone understands the policy, Nemeth has written a discharge policy for the hospital that explicitly states what the steps are for discharge and admission and the responsibilities of each member of the discharge team. The case management team created a discharge order form two years ago that physicians use to enter the patient’s discharge needs ahead of time. (To see the form, click here.) The form helps case managers anticipate a patient’s discharge needs, giving them the opportunity to start planning for home care and complete patient teaching in advance.

The physicians fill out the form shortly after admission with an anticipated discharge date but don’t sign the actual discharge orders until the patient is ready for discharge. For instance, the form has a place for the physician to indicate services such as durable medical equipment, home health services, or infusion therapy and whether a patient needs a follow-up appointment. The form lists the anticipated discharge destination and medications that may be required for discharge. "We encourage the physicians to be proactive rather than waiting for the day the patient is going home to order whatever the patient needs," she says.

The physician staff are encouraged to participate in the care management team’s "Daily Huddle," a 15-minute morning meeting of interdisciplinary team members who are responsible for the care of their particular population.

Membership in the Daily Huddle meeting depends on the individual team and the needs of the patients whose care they coordinate. For instance, in addition to the nurse case manager and social worker, one team includes a pharmacist, the nurse case manager, social worker, and physician assistants. An occupational therapist and physical therapist are on another team. "We like to have someone representing the physician group to attend. The utilization review person often attends the Daily Huddles as well. The purpose is to get everybody on the same page and make sure everybody understands the plan and what’s coming next," she says.

During the brief meeting, the team goes through the list of patients on the unit, sets priorities as to when they are going home, discusses the plan of care, and decides what needs to be done so the patient will be discharged on time.

The Daily Huddles were begun last year at the same time the case managers and social workers began sharing a caseload and working together as a team. The care teams are assigned by service, allowing the same social workers and case managers to work with the same types of patients and the same physicians. "Teaming up social workers and case managers has been well accepted by everyone, and they seem to be working well together," she says.

The individual care management teams have divided the responsibility for patient care between the two disciplines. The social workers tend to provide the bulk of management for patients who are covered by Medicare, Medicaid, or other publicly funded programs. The nurse case managers deal more with private insurance and commercial payers. "There’s a lot of interchangeability among members of the team. In general, the social workers concentrate on financial issues and psychosocial needs, while the nurse case managers deal with medical issues and clarifying plans with the physician and families," she says.

Here are some other initiatives the hospital has undertaken to improve the efficiency with which patients are discharged:

• Discharge planning prior to admission.

When patients have a planned procedure, such as a total hip replacement, the care management teams starts to work with them before the surgery, letting them know in advance what to expect and looking at what issues might affect discharge. In the case of patients who may be going to another part of the continuum, such as a skilled nursing facility or rehabilitation facility or who may have home care needs, the team may start the discharge planning process before the patient is admitted.

• Coordinating transportation needs in advance.

The care management team frequently coordinates with the ground discharge team, alerting them in advance if any of the patients has transportation needs, such as an ambulance or a wheelchair van, so the patient’s discharge won’t be delayed because of transportation issues. The care management team is starting to arrange for cabs in advance if patients will need a ride home.

• Identifying alternative medications.

MUSC case managers often encounter a problem with patients who cannot afford to pay for all the medications they need when they leave the hospital. "We know that patients who don’t take their prescribed medicine might be readmitted too soon. In many cases, physicians are reluctant to discharge a patient who can’t afford to fill their prescriptions," Nemeth says. In those cases, the case managers work with the physicians to identify less costly medication alternatives that will be as effective.

• Piloting wireless communications.

One care management team is piloting a wireless computer system that allows them to record their interventions and start discharge planning in the patients’ rooms and print out any documents they may need at any printer in the hospital. The initiative will increase the efficiency of the case managers and keep them on the floor working with patients instead of having to go back to their offices to use a computer. "Their documentation can be more real time. This system can be very efficient. It’s working very well so far," Nemeth says.

The hospital hopes to be able to roll out the wireless system to the entire department by the end of the year.