Critical Path Network
Proactive discharge planning keeps LOS low
Case management starts at every point of entry
By focusing on discharge on Day 1 and during daily multidisciplinary rounds, Scott & White Healthcare in Round Rock, TX, has maintained an average length of stay for Medicare patients of just 3.2 days and achieved a 30-day readmission rate of just 3%.
"Case management starts at every point of entry — from the emergency room to Scott & White Healthcare Systems clinics, outlying clinics, and other hospitals. We work together as an interdisciplinary team to ensure that all tests, procedures, and consults occur in a timely manner," says Nancy Wagner, RN, CCM, CPUM, CPUR, director of case management at the 2-year-old hospital with an average daily census of 35.
The case managers review every patient every day and work with nurses, physicians, and ancillary services staff to make sure the patients' needs are being met.
Case managers lead the hospital's multidisciplinary rounds each morning. The case managers discuss the patient's treatment plan and barriers to discharge, and pull in whichever team members can help.
"We spend additional time in rounds on Wednesdays to be sure that the details of the discharge plan are prearranged and communicated to all people on the treatment team," Wagner says.
On Day 1, the multidisciplinary team discusses the treatment plan, with each discipline focusing on his or her part of the treatment.
"We touch base on different issues each day and make sure all the patients' needs are met. Each day, there are different needs because of the short length of stay. On the day of discharge, we go over the discharge package to make sure everything is in place," Wagner says.
The team works to ensure that patients have a smooth transition throughout the continuum of care.
"One of the big advantages is that we start the multidisciplinary rounds on admission. Case managers screen the patients' acute care needs prior to admission and confer with the emergency department physicians, the clinic doctors, and the hospitalists to identify barriers for discharge up front," Wagner says.
For instance, if a patient in the ICU is intubated and likely to need a tracheotomy, or may need complex wound care after discharge from acute care, the team looks at the patient as being a potential transfer to a long-term acute care hospital (LTACH). In that case, the case manager consults the doctor early in the stay about ordering a transfer to an LTACH.
The team sets up a family meeting early in the stay and invites representatives from the post-acute provider to attend.
At Scott & White-Round Rock, the case managers and hospitalists have a close working relationship and work side by side on the medical units.
When the hospitalists sign out of the hospital at the end of their day, they send a daily round update on each patient to the hospitalist team, the case managers, and the nurse managers.
"These updates include current information on what is going on with the patient. If it's a new patient, the update includes the diagnosis, the work-up, the treatment plan, and the anticipated discharge date. It's really helpful to receive clinical updates on our patients every shift, every day," Wagner says.
The report alerts case managers when patients are receiving observation services but an inpatient stay is possible, pending tests.
The Scott & White system has developed a case management protocol that takes deciding the patient status out of the hands of the physician. Instead, the case managers determine the status and the physicians sign the admit order if they agree on the case manager's determination.
The goal is to have every chart reviewed and correct status assigned for every patient, Wagner says.
By focusing on discharge on Day 1 and during daily multidisciplinary rounds, Scott & White Healthcare in Round Rock, TX, has maintained an average length of stay for Medicare patients of just 3.2 days and achieved a 30-day readmission rate of just 3%.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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