Medically complex cases present a challenge

System helps with those who are hard to place

Today’s discharge planners face the challenge of finding post-acute services for patients who, thanks to improvement treatments and technology, survive more catastrophic illnesses and injuries than ever before.

However, many of these patients are medically stable and need to go to a lower level of care. Finding a facility that will take clinically complex patients often is difficult for hospital discharge planners.

"Discharge planning is extremely challenging for patients who have needs outside the typical cookie-cutter skilled nursing facility approach. What’s left in the hospital are the acutely chronically ill with extraordinary discharge needs," says Daryl Morgan, LMSW, discharge planner at Atlanta’s Crawford Long Hospital.

One of his most recent challenges was to find a nursing home placement for a paraplegic patient who weighed 700 pounds. The patient had a number of social and family issues that made it necessary for the hospital to pursue nursing home placement for him.

"The family insisted on something in metro Atlanta. For us, it was like pulling a needle out of a haystack," he adds.

In another case, after searching for two months, Morgan found a facility in Chicago that would take a ventilator-dependent patient only to have the patient’s daughter make a last-minute request to transfer her father to a facility in Columbus, OH.

"Because of the inordinate amount of time we spend working on hard-to-place patients, we may keep other patients in the hospital inadvertently longer than necessary because of time constraints and human resources," Morgan explains.

Like most major medical centers, Crawford Long winds up with a large number of patients who have few, if any, financial resources.

"We start discharge planning when they come in the front door. We identify patients who are going to have post-discharge needs up front and start working with the families to see what resources are available," he says.

Morgan starts talking with the physicians early on to get a clear picture of the patients’ prognoses and helps them apply for disability benefits if they are expected to be permanently disabled.

The 700-pound man had some benefits, but because of his size, most facilities didn’t feel they could manage his care. "Some facilities around town will take Medicaid patients or an occasional patient with limited resources. The trick is to find them, particularly facilities that will take people who are acutely ill and who have a high level of needs," he says.

The state of Georgia has few facilities that take weanable ventilator patients. That poses another challenge to discharge planners, Morgan adds. "Families always want their loved ones to be in a facility close to home, but it’s extremely difficult to find a nursing home that accepts ventilator patients in the state of Georgia. People believe that if you’re in an urban area, there’s got to be a place for their family member, but that’s not always the case."

Automated system was solution

Morgan found a solution to his problems finding placement for medically complex patients using the Extended Care Information Network (ECIN), an automated discharge planning and referral management program.

Unlike some other discharge planning software programs, ECIN allows hospitals to use its services on a case-by-case basis rather than signing a contract for long-term use.

Many hospitals with a lot of hard-to-place patients sign up for the service on a permanent basis, but others opt to use the service on an as-needed basis, says Bill Keyes, vice president for national accounts for the Chicago-based provider of web-based automated discharge planning and referral management software.

"It works very well. There’s no commitment on the hospital’s part, and the fee is less than a single day in the hospital. We found that after working with many hospitals around the country, some — either due to budget issues or other issues — don’t have the financial resources to purchase a full system, but they still have many hard-to-place patients," he says.

Instead of faxing multiple pages to 15 or 20 providers, the case manager sends the information on the client who needs placing to ECIN and it’s entered into a database.

"A hospital may have to spend 15 or 20 hours looking for providers. Our case manager enters the information into our system and within a day can contact hundreds of providers," Keyes says.

In compliance with Health Insurance Portability and Accountability Act regulations, the information does not have identifiable patient data. It contains diagnosis and needs. If the provider is interested in the patient, ECIN can provide more detailed information.

Having access to a large database of providers saves a lot of time and costs for hospitals, Keyes says. "Anytime patients leave the hospital, case managers or social workers are faxing information to multiple places."

Scripps Health, based in San Diego, did a time-and-motion study at one hospital before trying out the ECIN system, says Mary E. Whitehead, systemwide director for case management.

Before using ECIN, the hospital had a 1.3 hours response time from providers. Within the system, the figure dropped to 20 minutes, essentially saving an hour per referral, she says. "What we’ve seen is that the process of discharge planning is more thorough and efficient. We now can say that we have a 20-minute provider turnaround time and a 90% placement rate."

Scripps has different hospitals with different payer mixes and different operations models. Out of five hospitals, three use ECIN totally and do all discharge planning electronically, Whitehead says. "One of our biggest challenges is the process of communicating with providers regarding referrals. Every hospital in the system is different. In the past, most of them made phone calls, then faxed the information and waited for a response from the provider. It’s a very time-consuming process for every case manager in every hospital to be calling all the providers in the area."

Before signing up with ECIN, the discharge planners provided patient criteria to skilled nursing facilities or home health and waited for a call back. The case manager then faxed the history and physical, progress notes, lists of medication, and pieces of the medical record. With ECIN, the process is completed electronically.

"The providers have to be able to read the information and decide whether they will take the patient based on the information they receive," Whitehead says. Some skilled nursing facilities have just one intake person, and it can take days for the discharge planner to get a return telephone call, she adds.

"What ECIN does is provide an electronic connection through the Internet so a case manager can send electronic referrals to a skilled nursing facility or home health agency with patient demographics and clinical information using point-and-click technology," she adds.

The system saves time, cuts down on avoidable days, and helps free up beds for other patients, Whitehead explains.

"There is a lot of emphasis on patient through-put within our hospital system. We are challenged every day to decrease length of stay and improve patient throughput," Whitehead says.

It’s also a boon for discharge planners when a family member wants the patient to be transferred to a skilled nursing home facility in another state.

"Case managers can select a certain geographic location and find all the providers in that area," she adds.

The system allows the case manager to print a discharge package with information about post-acute choices, a feature that Morgan finds useful in helping families of difficult-to-place patients understand that the hospital has made every effort to find a facility near their home.