Good data come from internal discharge system
Coding system identifies systemic issues
Once a health care system decides to improve its discharge planning process, the difficult next step is collecting information about what doesn't work and how to improve flawed processes.
Stony Brook (NY) University Medical Center developed an internal coding system that has worked well as a solution to this dilemma.
"We decided that in order to address and make some more global and executive-level decisions, we needed to know the barriers to discharge," says Catherine Morris, RN, MS, CCM, CMAC, executive director of care management at Stony Brook University Medical Center.
"We might have a gut feeling that the discharge problem involved insurance, or a behavioral issue, or family issues, but we didn't have any way to quantify that, so we put together barrier codes and tracking codes," Morris explains.
The coding system has worked well, highlighting systemic barriers, according to Morris.
Once this systemic barrier was identified through the coding system, the hospital began to work on finding a solution.
Since the hospital's census remains at 98%, there is a continual supply of patients needing beds. This means the hospital's overall financial health benefits from providing care more efficiently and making timely discharges.
Since installing the discharge barrier coding system nearly three years ago, the hospital's average length of stay (LOS) initially decreased, but eventually remained level at about five days.
"Without this system, the LOS would be worse, because our census has included more difficult cases in recent years," Morris says. "We have a lot more uninsured patients."
"There definitely are millions of dollars in revenue to be generated as we get better and better at quantifying what are the barriers that hold patients in the hospital," Morris says.
Here's how the discharge coding system works:
Develop coding barrier categories. Stony Brook uses five different categories for the barriers, including the following:
acuity level divided into 1a, 1b, 1c, etc.;
community resource issues;
patient or family issues;
financial or insurance issues;
medical team.
For example, if the patient is given an acuity code, then it means the patient has acute needs that require hospitalization, and this is what is keeping them in the hospital longer than expected. A category 1a acuity code refers to a patient who is too clinically sick to be discharged, Morris says.
A 1b acuity code refers to patients who might need suctioning every one or two hours, and there are no local, sub-acute facilities capable of handling such a patient, she adds.
"So, we would talk with a respiratory therapist and look for things that could be done, such as re-evaluating the patient," Morris says. "Sometimes we cannot do anything except track the issue."
Another acuity code might refer to patients who are receiving care in the intensive care unit (ICU), although they do not need an ICU level of care.
This might occur because the medical team is delayed in downgrading the patient's care, or there is indecision because the team cannot agree on a discharge plan, Morris says.
When this barrier is identified, the solution might be to have the physician advisor see the patient and assist in decision-making.
Develop tracking coding categories. Each patient is given two barrier codes and two tracking codes.
"We have eight tracking codes, which are end-stage renal disease, mentally disabled, psychiatric patients, child protective services, undocumented patients, expensive treatment, alternative level of care, and expensive treatment," Morris says.
Since initiating the coding system two years ago, they've added and fine-tuned codes. For instance, the tracking code related to expensive treatment was added when this issue popped in the data, she adds.
"We have people with normal insurance, but the drug they're on is equal to or more than their daily insurance rate," Morris explains. "So, we can't send them to a nursing home, because the drug is so expensive; and we can't send them home, so they end up staying in the hospital."
Meet regularly with staff to discuss discharge codes, issues. "We have weekly meetings with staff to get a real understanding of what's going on with the patient," Morris says. "Representatives from finance and managed care, directors of the departments, including the director of case management and social work, the medical advisor, nursing management, and I meet to discuss what's going on with the patient."
They talk about patients' barriers to discharge and how these can be addressed and resolved.
"The staff discusses what's going on with the patient's activities, discharge barriers, and other problems," Morris says. "Then, the director and I sit together with the staff to make a final decision about the codes."
Supervisors can select codes for patients, but the discharge team can change these.
"We do some reliability testing to make sure everyone is defining things in the same way and thinking the same way," Morris says. "We make sure it's valid, and that everyone is coding the same way."
For instance, the finance representative might help the patient apply for Medicaid if the main barrier involves insurance and family income issues.
In cases of patients who are undocumented and who need sub-acute care that's not available for them in the United States, the hospital team might look into resources in the patients' home nations or arrange for the patients' families to come and take care of them.
"We might have a social worker meet with a family that is estranged and redevelop that tie with the patient," Morris says. "Or, we might need to work with a facility about receiving charity payment for the patient's care."
Find the best solution to barriers: Financial issues tend to be one of the types of barriers that sometimes require creative solutions.
"One of the big things we've done is form two special accounts that we fund to help patients who are staying in the hospital because of medication needs and their lack of funding or insurance," Morris explains. "So, if the patient needs IV medications, we help the patient get this in the community, so we can free that bed."
The hospital team might work with different companies to get the medication donated or have the risk shared. Sometimes the patient can pay a little, and the hospital will pay for the rest out of the special fund, she adds.
In another example, patients sometimes need a new medication that is very expensive and poses a barrier to discharge. In this case, the hospital pharmacist would review the drug to make certain it is the optimal medication for treating the patient and to see if there are any alternative drugs that would work as well.
Source
Catherine Morris, RN, MS, CCM, CMAC, Executive Director of Care Management, Stony Brook University Medical Center, Stony Brook University Medical Center, Stony Brook, NY 11794-7019. Telephone: (631) 444-7471.
Once a health care system decides to improve its discharge planning process, the difficult next step is collecting information about what doesn't work and how to improve flawed processes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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