Hospital’s SNF placement initiative improves efficiency, speeds discharge
30% of patients are placed within 24 hours
Before Dartmouth-Hitchcock Medical Center started an initiative to improve the transition of patients to skilled nursing facilities (SNFs), about 12% of the Lebanon, NH, facility’s patient days were patients waiting for SNF placement.
Now, three years after a task force tackled the problem, the hospital is experiencing only 5% to 6% of its patient days related to patient wait for a nursing home.
The hospital averages about 100 nursing home placements per month, up from about 80 per month two years ago. About 30% of patients who go to a nursing home are referred and placed within 24 hours.
"We’ve increased the volume of patients being placed and decreased the number of days we have patients waiting for nursing home placements," says Sandy Dickau, RN, MS, vice president of patient and family resources.
The new efficiency has increased hospital capacity. The team has calculated that in the past year, as a result of moving nursing home patients out more quickly, the hospital had capacity for more than 180 patients it otherwise would not have been able to admit.
"We have taken the whole concept of an interdisciplinary team and collaboration to a real state of being," Dickau says.
A task force with representatives from care management and finance, as well as several medical directors looked at ways to increase the efficiency of nursing home placement.
The task force reorganized the care management work by creating a centralized process for SNF placement and involved the physicians in a greater way.
"One of the things we recognized is that we needed to reorganize the work to make it more efficient to handle the patients’ transition needs," says Dickau, who chaired the task force.
Before the redesign project, Dartmouth-Hitchcock had inpatient care managers, called clinical resource coordinators (CRCs), who handled care coordination for the patients, utilization management, and discharge planning and were responsible for all SNF placements.
They were assisted by a resource specialist, an RN, who did a lot of the initial contact work with the SNFs.
"Our volume of nursing home patients was really increasing, and it was putting a strain on the CRCs. In addition to handling all the other patient care, they were setting up family meetings and working with the family to help them make a decision on post-discharge care," says Darlene Saler, RN, BSN, MBA, director of care management.
The care managers at Dartmouth-Hitchcock are assigned by medical service. Often, three different care managers were calling the SNFs to get three different patients placed in the same vacant bed.
"The lack of coordination meant that sometimes we were competing against ourselves for the same nursing home bed. The resource specialist was trying to make all the contacts and coordinate placements, but she couldn’t do everything," Saler says.
The hospital added another full-time resource specialist with a bachelor’s degree in human services who works with the nurse resource specialist on nursing home placement.
The resource specialists are dedicated to the SNF placement program and are assisted by a secretary who works with them on behind-the-scenes tasks such as handling paperwork, collecting charts and other information, and doing database entry.
The hospital established a new position of associate medical director for skilled nursing placement. The full-time equivalent position is shared by three physicians.
"Their focus is on the complex patients we had a difficult time placing and creating a bridge between our organization and the community nursing homes," Dickau says.
The task force recommended improving relationships with community nursing homes, an initiative that has resulted in the resource specialists being notified in advance when nursing home beds will be available.
The clinical resource coordinators, resource specialists, and associate medical directors work closely to come up with the best treatment plan for the patients and to decide whether they are more appropriate for an acute rehabilitation center or a SNF.
The managers in the care management department and resource specialists meet twice a week and go through the list of patients, discussing which patients are nearing readiness for discharge, what options are available to meet the patients’ needs, and what barriers to discharge may exist.
"We decide who are the priority patients and get one of the associate medical directors involved if necessary to determine if the patient is appropriate for a SNF or should go to acute rehab or even home," Dickau says.
The associate medical directors focus primarily on patients who will be discharged to a nursing home but also work on patients with complex discharge needs who may be discharged with home health.
They communicate closely with the medical directors at the insurance companies and community nursing homes and often facilitate a placement.
For instance, one of the associate medical directors, a physiatrist, convinced the medical director of an insurance company that acute rehabilitation was an appropriate placement for a patient with severe head injuries.
"Without the intervention, the patient would have had to stay here," Saler says.
The associate medical directors work closely with the attending physicians and nursing home medical directors as well. They are particularly effective in helping nursing homes develop a plan of care that allows the patient to stay in the SNF rather than being hospitalized, Dickau says.
In another instance, the associate medical director facilitated the discharge of a patient funded by the Veterans Affairs services. The patient was stable enough to be discharged, but there were no beds for him at the local VA hospital. The Hitchcock staff suggested placing the patient in a nursing home, but the VA balked at paying for transportation for the patient to come to the medical center for dialysis.
The associate medical director intervened and got the patient moved.
"It just took moving it to that next level to get the physician at the VA to hear what our doctor had to say," Saler says.
Last spring, clinical resource coordinators began staffing the emergency department (ED) and at times have been able to place a patient directly to the nursing home from the ED.
The ED CRC may start the discharge plan, discussing placement options with the patient and the family in the ED.
If the patient is admitted, the CRC covering that inpatient service is responsible for initiating the plan.
"We start looking at nursing home placement when we know it may be an issue for the patient. The timing depends on a lot of factors," Saler says. "If a patient has not been doing well at home, we might suggest that the family consider a SNF early on."
As the new system progressed, the Dartmouth-Hitchcock team has identified several areas for improvement.
For instance, the hospital created a referral form to alert the resource specialists of potential SNF placements.
"We get them on the list even though we know it may be weeks or days before we need a placement," Saler says.
The new efficiency and quick referral to nursing homes puts an extra burden on staff to help patients and families adjust to the idea, she added.
"We are looking at ways we can do a better job of letting patients and families know up front that this is a possibility," she adds.
The staff created a booklet for patients and families, listing all the possible discharge options.
"It took a lot of work to make this information inclusive and complete. We make sure we get it to all the patients and families early on so they can see that there are a lot of very different options and so they can understand the Medicare regulations around nursing homes," she adds.
Before Dartmouth-Hitchcock Medical Center started an initiative to improve the transition of patients to skilled nursing facilities (SNFs), about 12% of the Lebanon, NH, facilitys patient days were patients waiting for SNF placement.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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