Discharge Planning Advisor-On-line reservation system brings DP into 21st century

Allows time with patient instead of fax machine

Discharge planners at several hospitals in the Northeast are arranging patients' post-acute care through an on-line reservations and booking system that promises to revolutionize the discharge process.

In several pilot projects with the recently founded Integrated Health Networks (IHN), based in Newton, MA, hospital discharge planners are using a new software tool to determine the availability of post-acute services, then request and schedule those services over the Internet, says Ruth Fisk, RN, MS, vice president of clinical operations for IHN.

The three-month pilot projects will be completed in mid-May, with the new system expected to be available commercially to other hospitals by the end of May.

The system works like this:

• Post-acute providers that take referrals from a hospital, including skilled nursing homes (SNFs), home health services, and rehabilitation facilities, complete a profile outlining the services they offer. Each day, the provider updates the bed or service availability.

• Case managers or discharge planners working on a discharge plan input the patient's care needs and the date the hospital would like to discharge the patient. At this point, the specific patient is not identified.

• The system matches the availability of facilities or services with the needs of the patient.

• The discharge planner sends a notice via e-mail to the matched provider, by way of a secure Internet server, that a bed or service is being sought.

• The provider's intake coordinator reviews the patient care needs on the Web and responds to the hospital discharge planner.

• The patient and/or family is consulted in the final selection of the post-acute provider.

• To protect patient confidentiality, identifying information on the patient is sent to the provider only after the final match is made.

Program sets 2-hour time limit

The entire communication between the levels of care is done through electronic messaging, and the time given to respond is limited in both directions, Fisk points out. "If providers don't respond within a specified time, they're no longer on the list. This arrangement is agreed upon before providers are enrolled in the system."

Based on information from focus groups, IHN recommends that the nursing home or home care service be given two hours to respond to the hospital regarding acceptance of the patient, says Jackie Birmingham, RN, MS, CMAC, a veteran discharge planning and case management consultant and IHN's director of network integration.

"The provider needs to make a decision, that it will either take the patient or not, or will send a nurse to the hospital to assess the patient," Birmingham adds.

If the provider sends a nurse, it will be given another two hours before the process goes to the next step, she says. "In fairness to both sides, the provider should either do an assessment of the patient within two hours or respond to the hospital and let them know a liaison will be there in three hours."

Whatever happens, Birmingham points out, the case manager or discharge planner can always override one choice and go on to the next.

System eliminates distractions

Some nurse liaisons who do preadmission assessments have expressed concern that the on-line discharge system will prevent patient screening, but that is not the case, Birmingham emphasizes.

"We want the patient to be screened for appropriateness to the nursing facility or home care service," Birmingham says. "We believe that once discharge planners and post-acute providers gain experience with the system, the appropriateness rate will improve significantly and only a few patients — in cases where the patient's needs are complex or where the destination isn't sure because of the complexity — will need to be screened."

At the alpha test pilot site, Fisk says, the patient populations targeted will be a selected group of those being discharged at any one time. Half the discharge planners involved in the pilot work with patients enrolled in a risk-based Medicare program, and the other half work with traditionally insured patients, she adds. These discharge planners will work with patients only on selected units, which allows a built-in comparison group.

One big advantage of the IHN system is that "there is a considerable reduction in the amount of time that has to be expended in making discharge arrangements," Fisk says, "not just elapsed time, but time spent communicating with providers. Who has a bed? Who will accommodate certain requirements? We hear from case managers who now can spend an hour or two on the phone just determining who has a bed available and the appropriate services for the patient."

The system eliminates such distractions as busy signals, multiple faxes and the need to leave and respond to voice messages, she adds.

"It has been reported that the typical hospital discharge conducted via telephone and supported by paper, on average, may take more than four hours to complete," Fisk says. "The same transaction conducted electronically is estimated to take less than 45 minutes to complete."

High-tech becomes high-touch

Ironically, this high-tech discharge solution actually can facilitate closer communication among families, Fisk points out, particularly when family members are spread out in different parts of the country.

"The general perception is that high-tech is more impersonal," she says, "but in this instance it really does expand the circle to include family, even if distant, and allows them to know the options and advantages of one facility or service vs. another."

A feature of the IHN system, adds Birmingham, will offer "patients and distant families access to what we're doing. We can e-mail the Web sites of nursing facilities to the families, where they can see a review of the nursing homes. They will have a unique code or password that will give them access to designated information they need to make a decision."

Patients matched to providers

Many patients go to two or three levels of post-acute care before finding the level that fits their needs, Birmingham points out, often because they don't go to the right place the first time. The IHN system will make a difference, she predicts, "because the discharge planner will have a work flow tool and the patient is matched to the provider based on needs and availability. Discharge planners also will have more time to work with the complex patient to develop a more precise discharge plan."

Response to the idea has been "phenomenal," Birmingham adds. "There is communication only when there is a piece of information and discharge planners don't have to wait for a phone call. I call it the 'virtual discharge plan.' Payers are also very excited about the work flow tool, since it will allow more real-time information and collaboration with hospital-based staff and post-acute providers."

[Editor's note: For more information on Integrated Health Networks, contact Ruth Fisk at (617) 630-1335, e-mail:ruthfisk@ihn.com; Jackie Birmingham at (617) 290-3365, e-mail:jbirmingham@ihn.com; or Mike Quilty at mquilty@ihn. com.]