Patient Satisfaction Planner

Hospital cuts overall length of stay by 1.3 days

A series of multidisciplinary initiatives has resulted in a 1.3-day decrease in length of stay (LOS) at Hackensack (NJ) University Medical Center (HUMC).

"With the help of case managers, the average length of stay has significantly decreased without adversely impacting quality or outcomes. In today’s economic atmosphere, you must be able to positively impact the length of stay as well as maintain our high standard for quality of care," says Pat Eason, RN, BSN, administrative director for case management services at HUMC.

HUMC is a private, not-for-profit teaching hospital serving the New York City metropolitan area. The hospital has grown from a 12-bed community hospital to a nationally recognized 683-bed university-affiliated medical center that runs at a 92.5% occupancy rate.

The administration at HUMC established a care coordination committee several years ago to develop strategies to integrate performance improvement principles with LOS and resource management procedures and programs.

"The administrators realized that increases in chronic illness, shorter lengths of stay, complexity of care, and expansion of technology resulted in changes in the delivery of health care. The rising cost of care, the demand to control costs, and changes in reimbursement necessitated the provision of the most cost-effective quality of care. These changes translated into the need for better coordination of patient care across disciplines and services, especially for high-risk groups of patients," Eason says.

One of the major initiatives HUMC has undertaken is multidisciplinary care coordination for the delivery of patient-centered care that begins at the unit level. "We are dedicated to providing health care services of the highest quality, providing the patient with the right care at the right time and the right setting," she adds.

A key component of the initiative is daily multidisciplinary care coordination rounds, led by a physician, on all units Monday through Friday. In addition to participating in the multidisciplinary care coordination rounds, case management services undertook departmentwide initiatives that have contributed to the decrease in LOS and an increase in patient satisfaction, Eason notes.

Among the initiatives are case management or social worker visits to 100% of medical-surgical patients within 24 hours of admission, personal visits by case management services team members to patients who have been discharged to other facilities, and direct conversations with insurance companies instead of faxing information or leaving messages on voice mail.

The multidisciplinary team participating on the care coordination rounds includes physicians, case managers, social work professionals, nurse managers, advanced practice nurses, staff nurses, pharmacists, nutritionists, physical therapists, and others as needed. "These rounds provide a forum for the multidisciplinary team to collaboratively review and facilitate the patient’s plan of care and share this information with the attending physician," Eason says.

The purpose of the rounds is to ensure the appropriate care plan is in place for the patient’s acute problems; assist attending physicians in providing timely services in the appropriate setting; and collect, trend, and report data on service delays to the respective medical directors, departments, and multidisciplinary teams, she explains.

"When a variance in care or a barrier to moving a patient through the continuum is identified, the appropriate team member is assigned to address the issue and remove the barrier. Having a group of people with advanced clinical skills involved with the patient’s care results in a well-coordinated plan of care," says Theda Gunsher, RN, MA, operations manager for case management services.

Case managers and social work professionals are an integral part of the multidisciplinary rounding team on each unit, Eason adds. They are involved with the patient and family from admission to discharge and are responsible for keeping the team updated on the discharge plan and resource needs of each patient.

They work with ancillary services, ensuring that testing and reporting are done in a timely manner. For instance, if a patient is scheduled for an X-ray at 3 p.m. and could be discharged pending the result, the case manager works with the radiology department to have the X-ray done earlier and ensures the results are communicated to the physician in a timely manner.

Case management services at HUMC include RN case managers, social work professionals, RNs who work on denials and appeals, and analysts. The organization has an integrated model of case management that includes utilization review and management, discharge planning, and in some situations, transitioning patients to rehabilitation hospitals or other post-acute facilities. Case managers are unit-based with assigned caseloads based on the size and acuity of the unit. Some case managers may be assigned more than one unit, while high-acuity units may have two case managers.

The overall LOS on each unit is a good indicator of how many case managers are needed to staff the unit, Gunsher adds. For instance, the orthopedic unit has a rapid turnover, with 10-plus admissions and discharges on a daily basis. That unit needs more case managers than a unit where patients stay several days.

The target case ratio is one case manager to every 15 patients when the case manager performs three roles: utilization review, discharge planning (setting up home care, durable medical equipment, and infusion therapy), and transfers to rehabilitation facilities. For case managers performing two roles — utilization review and discharge planning — the target case ratio is one case manager to 20 patients. The hospital’s high census makes it difficult to always maintain these target ratios, Gunsher says.

Social work professionals are responsible for transitioning patients to extended care facilities, crisis intervention, substance abuse and mental health treatment, and patient advocacy as well as referring patients to entitlement programs such as Medicaid, pharmaceutical programs, and other community resources.

When case managers transition patients to rehab facilities, they meet with the family to develop an appropriate discharge plan and often provide a list of area facilities for families to visit. Once the patient and family have decided on a facility, the case manager arranges transportation, develops the plan for the transfer, and works with the case managers at the receiving facility.

The hospital strives to cluster similar-type cases in certain diagnoses. For instance, one unit is dedicated to stroke and CVA patients, and another is dedicated to heart failure.

"When the census is as high as ours usually is, you have to assign beds where they are available. Some units have more patients than others. The highest unit has the capacity for 33 patients, with the lowest being 14," Gunsher says.

Case managers at the medical center work staggered hours, with the first group arriving at 6 a.m. and the last group arriving between 9:30 and 10 a.m. They rotate being on call from 4:30 p.m. to 8 p.m. Monday through Friday. Two case managers and one social worker are on-site Saturdays, Sundays, and holidays. During the week, a full-time case manager and social worker are assigned to the emergency/trauma department.

Every patient in the medical-surgical unit receives a visit from a case manager or social worker who gives them a brochure explaining what case management is and what services they offer. "Seeing the patient within 24 hours of admission is truly beginning the discharge process on admission and has contributed significantly in reducing the length of stay. The case managers are able to pick up on potential problems they might not find in the medical record and can intervene much faster," Eason says.

For example, while talking to a patient, a case manager may discover that the patient is not capable of taking care of him- or herself at home or that the patient needs community services or help paying for medication. In other cases, the case manager may find that the patient has frequent admissions or visits to the emergency department and can intervene to prevent continued hospitalizations.

"We can decrease the length of stay when we address these issues early on rather than waiting until discharge to find that the patient does require some interventions," Gunsher adds. Visiting with every patient has increased the hospital’s patient satisfaction. "We found through our patient satisfaction surveys that some patients who didn’t require care at home or a facility felt we were not involved in their discharge planning. Now, either a social worker or a case manager assesses each patient and addresses questions they may have regarding their discharge, she explains.

In a new initiative piloted over the past several months, a case manager or social work professional visits each patient who has been discharged to an extended care facility to ensure a smooth transition to the next level of care. "It is reassuring to our patients to know we are concerned that they receive the appropriate post-hospital care, Eason says.

Visiting the extended care facilities gives staff a better understanding of the type of care that is provided and helps them provide feedback to physicians about which facilities would be appropriate for particular patients, she adds. If a patient is discharged to home with home health care, durable medical equipment, or by ambulance, the case manager follows up by telephone the next day to make sure the patient’s needs are being met.

"Both patients and families seem pleased with our post-hospital monitoring, and it also gives the case manager the opportunity to take corrective action if the patient is having problems. We haven’t been doing this long enough to know if we have cut down on readmissions, but that is part of our goal," Eason says.

At HUMC, the case managers do not fax information to insurance companies or leave messages on voice mail. "The case management services’ practice of talking to insurers one-on-one has had a positive impact on denial of payment. There is no misunderstanding about what is actually occurring with the patient because the staff speak directly to the insurance case manager and can provide additional information or answer questions as needed," she notes.

The practice has significantly decreased the number of phone calls between the HUMC case managers and the insurance companies, Eason adds. "Our case managers and the insurance case managers have gotten to know each other very well, and we now have current information on a patient’s status instead of waiting for decisions."

The hospital’s finance department is working with the insurance companies to change contract agreements on how frequently the case managers are required to review a case with the insurance company, she adds.

HUMC tracks all payer LOS and breaks out LOS for Medicare and managed care by both noncase mix-adjusted and case mix-adjusted length of stays. LOS is broken out by unit as part of a unit report card containing financial, clinical, and satisfaction indicators.