Throughput plan focuses on long-stay patients
Team looks at discharge options
In the first year of Saint Luke Hospital's initiative to improve throughput for long-stay patients, the length of stay for those patients dropped by 0.5 days and the number of avoidable days dropped from 160 in 2006 to 90 in 2007.
The Kansas City, MO, hospital takes a two-pronged approach to removing barriers to discharge for patients who have been in the hospital for more than 10 days, says Anita Messer, RN, MHSM, ACM, director of care integration at the 500-bed tertiary care hospital.
The case management department's long-stay committee meets twice a week for an hour and reviews all patients who have been in the hospital for more than 10 days.
The team picks out about five patients to be discussed in detail at the multidisciplinary long-stay committee, which meets twice a month.
The project started in 2006 when the case management department began reviewing their cases and trying to find solutions. The medical director, Peter Holt, MD, recommended the creation of a team made up of key players in the hospital who could understand the types of patients who were contributing to the avoidable days and long lengths of stays and determine the barriers to discharge.
The long-stay project tackles throughput issues by identifying barriers to discharge, such as no discharge destination, physician practice patterns, or other factors.
"We look at the discharge plan and any barriers to discharge, including physician issues, and determine where the patient should go and the time frame in which it should occur," Messer says.
The case management department meetings are attended by all social workers and case managers who are managing the care of a long-stay patient.
"Usually almost everybody in the department has at least one patient with a long length of stay," Messer says.
The case management department team typically discusses about 35 cases in each hourly meeting. They narrow down the cases they present to the multidisciplinary committee to about five, taking into consideration the length of the stay, the discharge barriers, and if they feel there may be a solution to the problem.
The case managers and social workers who are managing the patients present the cases to the long-stay committee, which includes administration, physicians, risk management, patient advocates, and the vice president of charity care.
"Their report starts at admission, includes clinical information, and identifies barriers to discharge," Messer says.
The formal committee focuses on the most difficult cases.
"Sometimes it's easy to find a solution. In other cases, we end up keeping the patient," she says.
Most of the patients are covered by Medicare or Medicaid or are uninsured. The team usually doesn't bring patients with private insurance to the committee unless their post-acute stay has been denied.
Sometimes physicians have been invited to talk about their cases.
"We present where we are and what they hope they will do. This has been successful in getting physicians on board with our discharge plan. The case managers do a good job of educating physicians on acute care criteria but sometimes it helps to hear it from another physician if a patient doesn't meet criteria," Messer says.
The long-stay committee looks at why patients who can be discharged to a lower level of care are still in the hospital and tries to find a way to overcome the barriers to a safe discharge.
The hospital has paid for a skilled nursing facility or long-term acute care stay for patients who no longer meet criteria for an acute care hospital stay but don't have funding for post-acute care.
For instance, one young patient had no source of funding and limited family support but needed rehabilitation in order to be safely discharged. Instead of keeping him in the hospital with physical therapy every day, the hospital paid for his stay in a long-term acute care hospital for a short period of time until the patient was approved for Medicaid.
Some patients need someone at home to care for them after discharge but don't have family in the area. If the family can't afford to provide transportation, the hospital has paid for a plane ticket or bus ticket to another state or even another country.
The hospital has paid for a few undocumented workers who needed care after discharge to go back to Mexico if their family agreed to care for them and the follow-up care they needed was available.
"In these cases, we work with the family and the Mexican consulate to arrange transportation and medical care in the patient's home town. Sometimes we can't send them back. We always walk that fine line of getting the patient back home safely with the therapy and care he or she needs," she says.
In some cases, the hospital has helped patients who have lost their jobs and still are eligible for coverage under COBRA but can't afford the premiums.
"If they can't pay, we may split the cost of insurance with them or their family so they will have some benefits when they leave the hospital," she says.
The committee has decided to provide equipment such as hospital beds or wound vacs if it will enable patients to go home with home health.
"It's more cost-effective for us to provide the equipment and pay for home health rather than keeping the patient in a bed that can be used by a patient who may be able to pay," she says.
As a result of the long-stay throughput efforts, the case management department has gotten a grant from the hospital foundation for its Difficult Discharge Fund, which pays for items and services that cost less than $500 so a patient can be safely discharged from acute care.
"The case managers and social workers have the authority to use the fund so that the administration and the long-stay committee won't have to deal with every problem discharge," Messer says.
For instance, the fund once paid for a bus ticket for a patient who was injured while working in Kansas City to go back to Oklahoma where he could receive follow-up care from the Veterans Administration Medical Center.
In other instances, if a patient who lived in another city was ready for discharge but couldn't get a ride home for a few days, the hospital has paid for a hotel room until the patient could arrange transportation home.
(Editor's note: For more information, contact Anita Messer, director of care integration, St. Luke's Hospital, e-mail: [email protected].)
In the first year of Saint Luke Hospital's initiative to improve throughput for long-stay patients, the length of stay for those patients dropped by 0.5 days and the number of avoidable days dropped from 160 in 2006 to 90 in 2007.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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