Discharge Planning Advisor: Health care seeks causes for discharge delays

Lack of resources, communication cited

What is the No. 1 reason for patient discharge delays? Discharge Planning Advisor posed that question to several leaders in the fields of discharge planning and case management. Their responses are below.

Kathleen Moreo, RN, Cm, CCM, CDMS, CEAC, co-owner of PRIME Inc. in Miramar, FL:

"I think the No. 1 barrier continues to be written/verbal communication. Discharge can’t occur because the doctor’s order isn’t in the chart . . . the written permission is not obtained . . . if the patient is going from one facility to another, the approval from the receiving physician hasn’t been received . . . or the approval from the payer hasn’t been received.

"From my training and consulting experience, this seems to occur more often than the fact that community resources don’t exist.

"Communication remains one of the most powerful tools — or barriers — to effective health care delivery. Delivery systems spend exorbitant time and funds on developing clinical guidelines and algorithms and revamping information systems while the fundamentals are often ignored.

"There is no doubt that one of the best tools in the discharge planner’s or case manager’s toolbox is skilled communication, coupled with effective relationships."

Psychosocial concerns cause major delays

Sandra Lowery, RN, CRRN, CCM, president of CCMI Associates in Francestown, NH, and immediate past president of the Case Management Society of America in Little Rock, AR:

"In my experience, psychosocial concerns are the No. 1 reason for serious delays. Under that category would be financing issues, decisions related to the environment they would be discharged to, and decisions related to the support services they would need, whether informal or formal. All of these pertain to the psychosocial needs of the individual more than the medical, although certainly both are affected."

Tina Davis, RN, MS, CMAC, senior director, continuum of care, Arnot Ogden Medical Center in Elmira, NY:

"The difficulty comes when there is an identified need and no resources to provide for it. It depends on the community you’re in and what services are available in the post-acute continuum. In our county, we have a shortage of nursing home beds so the wait for transfer to a nursing home can be quite long. We also struggle with the Medicare prospective payment system because it becomes difficult to provide home care for those who need it when Medicare won’t cover, and these people very often don’t have the resources to pay for it on their own."

Maria Hill, RN, MS, CMAC, senior consultant with the Center for Case Management in South Natick, MA.

"[The No. 1 reason] is lack of bed availability for Medicare/Medicaid-funded clients in a care facility in the patient’s community of residence."

Jackie Birmingham, RN, MS, managing director, professional services, for Curaspan Inc., in Needham, MA:

"Here are my top four reasons for delay in discharge from a continuum perspective:

  • lack of knowledge of bed availability in the post-acute setting;
  • locating the appropriate facility for the patient in relation to payer, and geography;
  • communication between hospital and post-acute intake;
  • transfer of medical information that can be used for post-acute care."

Marne Bonomo, PhD, regional director for patient access, Aurora Health Care in Milwaukee:

"One of our bigger discharge issues is getting a ride home. We are currently evaluating transportation options, meals to home,’ and medication to home’ to help expedite emptying rooms sooner whenever the patient’s condition permits.

"On our new bed management eBoard, one of the indicators is patients with discharge orders,’ so that social services and utilization [management] can easily see where they need to direct their resources. Also, in addition to length-of-stay teams for each individual hospital, we have oversight length-of-stay teams for our regions. Reduction in length of stay is one of our key strategic goals."

Lisa Zerull, RN, MS, program director, Valley Health System in Winchester, VA:

"The first thing to consider is the environment, whether it’s metropolitan or rural. With [our hospital] being rural, patients can live up to 200 miles away, so transportation is a big reason for discharge delays. We can discharge the patient at 9 a.m., but if the family can’t get here until 4 p.m., that person remains in our system. Another reason is physicians waiting until later in the day to discharge patients.

Physicians need incentives to discharge

"We work in an environment where managed care has not penetrated the market, so there is no incentive for physicians to get patients out faster. Something that has greatly impacted our length of stay is that we now have a hospitalist on board, so we don’t have to wait for a busy family practitioner to make rounds [to discharge patients]. The trend is for family practice offices that are very busy to contract with a hospitalist to care for patients when they are hospitalized."