Rethinking length of stay: New research disputes the link to cost savings
Focus instead on overhead and fixed costs
Early patient discharge, once thought to yield substantial cost savings, in reality has little impact on a hospital’s bottom line, suggests a recent study published in the Journal of the American College of Surgeons.1
The purpose of the study was to determine precisely how much hospitals save by shortening patients’ length of stay (LOS). Interestingly, the study found that patients’ costs decline dramatically at the end of a hospital stay. That flies in the face of conventional thinking: that cutting one day at the end of an inpatient stay reduces the overall cost by the mean cost of a day in the hospital.
The findings come as little surprise to some case managers, who are quick to note that the early phase of care involves expensive diagnosis and intervention, while the final days are mostly devoted to recuperation. "Certainly, procedures such as preoperative work [can] contribute to high costs," says Judy Homa-Lowry, RN, MS, CPHO, president of Homa-Lowry Healthcare Consulting in Canton, MI.
Elaine Cohen, EdD, RN, director of case management at University Hospital at the University of Colorado Health Services Center in Denver, agrees that one of the most effective ways to reduce costs is to plan ahead. "Ideally, discharge planning should begin at the same time a patient is admitted so that any major issues can be dealt with early on."
To help identify the needs of high-risk patients, the Health Services Center, as part of its nurses’ admission assessment form, devotes an entire checklist to issues relating exclusively to discharge planning. The checklist addresses a wide range of issues that could be problematic later on, including whether the patient:
• is elderly and living alone with no support;
• has no support outside the home (family/friends);
• lives with a disabled other;
• lives in a nursing home;
• is physically disabled;
• has frequent admits;
• is noncompliant;
• exhibits poor judgment;
• needs continuing care referral;
• requires transfer from the facility;
• is unaware of community resources;
• is at a financial deficit;
• has a life-threatening chronic illness;
• has transportation assistance needs;
• has a new diagnosis and requires education/ counseling;
• requires home oxygen;
• has other needs.
Staff at the center review individual cases on a daily basis to determine if there are any patients with discharge issues that require immediate attention. To do that, the center uses a triad model adapted from the Vanderbilt University School of Medicine in Nashville, TN. A triad is made up of a case manager, social worker, and a member of the utilization staff. The triad uses criteria from McKesson HBOC’s Interqual products group in Marlborough, MA. "We are then able to move [patients] into the appropriate area of care, whether that is inpatient or observation," Cohen says.
Most important, she says, is making sure that the patient is receiving the level of care best suited to his or her condition. "In some cases, a hospice or nursing home may be a more appropriate setting — although that determination ultimately has to be made by the physician with help from the health care team and, of course, the patient and family."
In some cases, agrees Homa-Lowry, hospitals will come out better all the way around by doing referrals — even if they do fall at the back end of a patient’s stay.
In the last analysis, rate of recovery — not cost of stay — must always be the overriding factor in determining when a patient will be allowed to leave the hospital. "Some patients recover very quickly; others do not," says Harriet Ables, clinical coordinator, utilization review coordinator at Baptist Health in Jacksonville, FL. "While I have no doubt that the [findings of the study] are valid, I believe very strongly that each patient should be looked at on an individual basis and not lumped into a criteria set."
Case managers overseeing patients’ discharges also need to take into consideration what sort of conditions the patients will be returning to, says Ables. "Some patients can go home on post-op day three because they live in a clean home with running water and neighbors nearby. Others cannot because they get their water from a cistern and literally live in the middle of a swamp. . . . Recently, we had a patient who stayed in the hospital much longer than average because his living conditions were so deplorable that no visiting nurse, including public health, was willing to go into his home."
For more information, contact:
Judy Homa-Lowry, RN, MS, CPHO, President, Homa-Lowry Healthcare Consulting, Canton, MI. Telephone: (734) 459-9333.
Elaine Cohen, EdD, RN, Director of Case Management at the University Hospital, University of Colorado Health Services Center, Denver. Telephone: (303) 372-7624.
Reference
1. Taheri P, Butz D, Greenfield L. Length of stay has minimal impact on the cost of admission. J Am Coll Surg 2000; 191:123-130.
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