Critical Path Network

Multidisciplinary efforts cut LOS, reduce readmissions

CMs move patients to appropriate level of care

At New York Hospital Queens, a series of multidisciplinary, hospitalwide initiatives helped the hospital cut its length of stay by almost a day, despite an increase in the number of patients.

"We are always looking to be more efficient and looking at ways to move the patient to the appropriate level of care, whether it's subacute, acute rehab, or home care," says Caroline Keane, director of case management and social work.

At the same time, the case management department examines the cases of patients who are readmitted within 31 days to determine the reasons for readmission and develop ways to avoid them.

LOS ongoing challenge

"We've always tackled length of stay. It's ongoing and involves everything from how we render care to how we move patients in and out of the hospital. This isn't solely about the case management department. Our efforts touched a lot of departments and enabled everyone to look at what they were doing and make improvements," Keane says.

At New York Hospital Queens, case managers are assigned by floor, with one to two case managers on any given floor, based on patient census. The hospital has increased coverage by case managers and social workers. Both disciplines cover the hospital from 7 a.m. to 8 p.m. and on weekends.

Case managers track avoidable days and enter them on a delay report. The multidisciplinary team analyzes the reports and looks for trends.

"We look at admissions, based on concurrent chart review, identify the reason for the delay, and look for opportunities for improvement," Keane says.

Keane meets with the department heads monthly to discuss their delay reports and address the issues.

"The case managers don't interfere in departmental work. We look at what we think the opportunities are," she says. For instance, the case managers work to get tests completed earlier and lab results and other reports out faster.

"A very big piece of lowering length of stay is getting patients ready for discharge. Many of our patients have very complex conditions and we can't push them out so fast that they're going to fail. We work together to figure out what their needs are and make sure they are met after discharge," she says.

Early discharge plans

Case managers at New York Hospital Queens make sure they establish the right discharge plans as early as possible. They assess and reassess throughout the stay and orchestrate the discharge plan.

The case management department uses a computerized discharge planning system that allows them to contact post-acute facilities on-line.

"We regularly meet with nursing to talk about discharge issues," she says. The case managers round on the floor with the nurse manager and other members of the treatment team, such as the physical therapist or the dietitian.

"Rounding has helped a tremendous amount in avoiding delays," she says.

At the same time the team was working to shorten lengths of stay, they also looked at hospital readmissions.

Relationship between LOS, readmissions

"If the length of stay drops and patients keep coming back, that's telling you the length of stay is too short. We want to make sure that we discharge the patients in a timely manner but that we don't aggressively push them out before they're ready," she says.

Keane and her team routinely go over the charts of all Medicare patients readmitted within 31 days.

"We make sure we didn't prematurely discharge them based on their medical condition and that we provided them with appropriate services on discharge. We look at the case management discharge plan to determine if it was comprehensive enough and if it impacted the readmission," Keane says. For instance, the team investigates whether the patient might have benefited from home care but didn't receive it. Sometimes the case manager has recommended the most appropriate plan but the patient or family is not in agreement.

"We do a lot of education and re-education about discharge planning," Keane says.

The team rarely finds examples of patients who are readmitted because they were discharged too soon, Keane says. Instead, it's for other reasons, such as that the family didn't agree with or didn't follow the recommendations that the case manager made in the discharge plan.

"We educate patients on what they should do post-discharge but we can't guarantee compliance with the plan," Keane says.

For instance, the case manager may have suggested that the patient go for rehabilitation and the family insisted on taking the patient home.

"The biggest issue is that patients and families are unrealistic as to how they can manage at home. The case managers may recommend placement in a skilled nursing facility or recommend hospice care but the family isn't ready yet," Keane says.

In the case of patients who are readmitted from a nursing home, the problem may be that the nursing home isn't equipped to provide the care that the patient needs or that the patient didn't receive the medications they needed because they were expensive.

If indigent patients can't afford their medication, the hospital provides them with medication and helps them tap into a pharmacy program that provides free or discounted medications. The case managers print out the paperwork necessary for a pharmacy program for the indigent patient and help them fill it out. They refer them to community clinics for follow-up care.

Dealing with indigent patients

"One problem is that the poor don't always know how to advocate for themselves. We try to connect them with community resources that allow them to receive appropriate services, but they often choose not to follow through. Sometimes they do not tell us that they are in need of assistance during their stay. Often they don't let us know they can't afford the medication," Keane says.

The case managers discuss which patients might be appropriate for hospice or palliative care. They look at whether the family structure might have affected the readmission and what steps they could have taken to make sure the post-acute needs of the patients were provided.

"I use the good and bad cases to educate the case managers. I blank out the names in a chart and talk about the circumstances, pointing out the opportunities for improvement. Sometimes we discuss a real case and on occasions, we create them," she says.

For instance, to educate the case managers and social workers on which patients are appropriate for palliative care, Keane called on representatives from a home hospice organization for help.

They worked together to create 10 hypothetical patients and asked the case managers and social workers to determine which are appropriate for hospice care and which are not.

"We bounce ideas off each other and learn from each other," she says.