CQI improves transition through the continuum
Case manager coordinates patient care
Before the rehab department at Parkland Health and Hospital System in Dallas began a quality improvement project, it took an average of 21.64 days for discharged patients to be scheduled for their first outpatient visit.
After a three-month pilot project using a case manager to coordinate care, the average time for outpatient therapy to be scheduled dropped to 4.2 days, an 80.59% improvement.
The staff undertook the project because of the dramatic drop in lengths of stay a decrease from 26.9 days to 17.8 days in just three years, says Nick Kagal, director of physical medicine and rehabilitation.
"The reduction in length of stay increased the importance of a quick and smooth transition to outpatient care," Kagal says.
Parkland’s 14-bed comprehensive rehab unit is part of a 1,000-bed county and teaching hospital. Most patients are treated by medical residents who rotate on and off the service at intervals. Many patients receive some type of tax-supported care, such as Medicare, Medicaid, or state-funded programs. Parkland patients often have fewer discharge options than private-pay patients and lack ready access to transportation for outpatient care.
The hospital administration appointed a quality improvement team with representatives from physical therapy, occupational therapy, speech therapy, social work, and nursing.
The team went through three days of continuous quality improvement training at a local training center to learn how to analyze problems, break down processes, and use techniques such as brainstorming to solve problems, Kagal says.
When the team began to break down the referral process from the rehab unit to the outpatient area on a flow sheet, they found "a frustratingly large number of variables," Kagal says.
Here are some of the problems they found:
• There was no formal mechanism for referring acute rehab patients to the outpatient clinic. Because the referrals were made by medical residents who worked in the department only temporarily, there was little consistency. Some residents would hand the orders to a rehab nurse; others would drop them off at the outpatient clinic.
• Orders for physical therapy and occupational therapy often arrived at the outpatient center at different times. This meant patients were in the position of coming into the clinic for physical therapy before their occupational therapy referral orders were processed, and there was no coordination of the various therapies a patient received in the outpatient setting.
• A large number of orders never arrived at the outpatient center.
• When patients were discharged, they often did not know when or where their outpatient therapy would take place.
• Patients who should have been referred to the Texas Rehabilitation Commission for post-discharge programs, such as work retraining and day programs, often fell through the cracks because there was no mechanism to track them.
• It took between three and 90 days for the first appointment to be booked after referral.
• Some patients couldn’t get to outpatient therapy when it was scheduled because of the time it takes to get a pass for the local rapid transit authority’s Handi-Rides service for the disabled.
The team recommended setting up a case management system to follow the patients’ progress from the day they were admitted to the inpatient unit through their referrals after outpatient therapy. The rehab unit manager acted as case manager during the three-month pilot study.
Under the new procedure, all orders for outpatient therapy go through the case manager, who works with the outpatient scheduler to coordinate times for occupational therapy, physical therapy, and speech therapy.
The case manager attends the weekly patient care conferences and identifies patients’ future needs, such as outpatient services and home health.
When patients are identified as candidates for outpatient services, the case manager takes a proactive role in obtaining the orders from the physicians and makes sure they are delivered to the outpatient scheduler.
The team developed a discharge package that includes directions to the outpatient gym, instructions on how to get a clinic card that will admit patients to the outpatient center, and a list of therapy appointments.
Staffers now begin the process of applying for a pass for the Handi-Rides transportation system for the disabled, operated by the local transit authority, as soon as the patient is admitted to acute rehab.
The team recommended that patients take a tour of the outpatient department before discharge and that patients sign a commitment statement acknowledging their responsibilities in the outpatient program.
Patients’ progress reviewed monthly
Parkland has set up a monthly team conference to discuss the progress of patients in the outpatient program. The team includes residents and faculty who saw the patient in the inpatient program, outpatient therapists, the case manager, and a Texas Rehabilitation Commission representative.
During the pilot project, in addition to the drop in length of time between acute care discharge and outpatient treatment, there was a 98% increase in orders being routed to the outpatient department.
After the pilot, patients were booked for their first appointment within two to nine days of referral, as opposed to taking as long as 90 days.
"We needed a tight continuum. Patients discharged from inpatient rehab have exercise and home programs to do, but if they come straight to the outpatient clinic, it helps us see how they are doing," he says.
Because of the success of the pilot project, the rehab department has plans to expand the case management program and has asked for a case manager’s position to be included in this year’s budget, Kagal says.
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