On-line booking smoothes discharge
At-risk patients identified electronically
Hospital access managers who count discharge planning among their areas of responsibility may be interested in a new on-line reservations and booking system that promises to revolutionize the discharge process.
Personnel at selected hospitals in the Northeast are using a new software tool to determine the availability of post-acute services, then request and schedule those services over the Internet, says Ruth Fisk, RN, MS, vice president of clinical operations for Integrated Health Networks (IHN), the Newton, MA, company that produces the software.
The system is one way to help bring the admitting process into the electronic age, says Jackie Birmingham, RN, MS, CMAC, IHN’s vice president of network integration. "With eDischarge, the identification of a patient who is at risk can be done electronically. The access person can automatically trigger a referral to the case manager."
That process is in keeping, Birmingham adds, with the ideal of having admitting personnel screen patients for certain high-risk criteria for discharge planning, including such factors as age, diagnosis, and living situation.
"Access people have a lot more information than they believe," she says. "I don’t think they know they can influence length of stay merely by having a suspicion of discharge problems. [Admitters] should have some training on how to look at the total patient, not only the admitting diagnosis. The admitting diagnosis is wrong a great deal of the time."
Three-month pilot projects of eDischarge were completed in mid-June 2000, adds Birmingham, a veteran discharge planner and case management consultant. The new system is now available commercially to other hospitals. It works like this:
- The post-acute care provider taking referrals from a hospital, skilled nursing facility, home health service, or rehabilitation facility completes a profile outlining the services those facilities offer. Each day, the provider updates bed or service availability.
- Hospital or other facility case managers or discharge planners working on a discharge plan input the patients’ care needs and the date the hospital would like to discharge them. At this point, the specific patient is not identified.
- The system matches the availability of facilities or services with the needs of the patients.
- The facility’s discharge planner sends a notice via e-mail to the matched post-acute care provider, by way of a secure Internet server, that a bed or service is being sought.
- The post-acute care provider’s intake coordinator reviews the patients’ care needs on the Web and responds to the facility’s discharge planner.
- The patient and/or family is consulted in the final selection of the post-acute care provider.
- To protect patient confidentiality, patients’ identifying information is sent to the provider only after the final match is made.
An electronic schedule
All communication among levels of care is done through electronic messaging, and the time given to respond is limited in both directions, Fisk points out. "If providers don’t respond within a specified time, they’re no longer on the list. This arrangement is agreed upon before providers are enrolled in the system."
IHN recommends, based on information from focus groups, that the nursing home or home care service be given two hours to respond to the hospital regarding acceptance of the patient, Birmingham says. "The provider needs to make a decision that it will either take the patient or not, or will send a nurse to the hospital to assess the patient."
If the provider sends a nurse, it will be given another two hours before the process goes to the next step, she says. "In fairness to both sides, the provider should either do an assessment of the patient within two hours or respond to the hospital and let them know a liaison will be there in three hours."
Whatever happens, Birmingham points out, the hospital’s case manager or discharge planner can override one choice and go on to the next.
Shortening discharge arrangements
Some nurse liaisons who do preadmission assessments have expressed concern that the on-line discharge system will prevent patient screening, but that is not the case, she emphasizes.
"We want the patient to be screened for appropriateness to the nursing facility or home care service," Birmingham says. "We believe that once discharge planners and post-acute providers gain experience with the system, the appropriateness rate will improve significantly and only a few patients — in cases where the patient’s needs are complex or where the destination isn’t sure because of the complexity — will need to be screened."
One big advantage of the IHN system is that "there is a considerable reduction in the amount of time that has to be expended in making discharge arrangements," Fisk says, "not just elapsed time, but time spent communicating with providers. Who has a bed? Who will accommodate certain requirements? We hear from case managers who now can spend an hour or two on the phone just determining who has a bed available and the appropriate services for the patient."
The system eliminates such distractions as busy signals, multiple faxes, and the need to leave and respond to voice messages, she adds. "It has been reported that the typical hospital discharge conducted via telephone and supported by paper, on average, may take more than four hours to complete. The same transaction conducted electronically is estimated to take less than 45 minutes to complete."
IHN can make program enhancements to meet the needs of individual organizations, Birmingham notes. The state of New York, for example, requires something called a "Patient Review Instrument," she says. With eDischarge, hospital personnel are able to complete the form on-line and submit it electronically.
"We also are able to enhance the assessment questions that a hospital would want to ask about discharge, then collect that data and report on it," Birmingham says. "There is a data bank within the [eDischarge] assessment tool, so we can add questions. We’re now up to about 700 questions."
This high-tech discharge solution can facilitate closer communication among families, Fisk points out, particularly when family members are spread out in different parts of the country. "The general perception is that high-tech is more impersonal," she says, "but in this instance, it really does expand the circle to include family, even if distant, and allows them to know the options and advantages of one facility or service vs. another."
A feature of the IHN system, adds Birmingham, will offer "patients and distant families access to what we’re doing. We can e-mail the Web sites of nursing facilities to the families, where they can see a review of the nursing homes. They will have a unique code or password that will give them access to designated information that they need to make a decision."
Finding the best fit
What is important about the IHN program, she says, is that it is designed as a "workflow tool for professionals that will allow discharge planners to spend time with the family and the patient instead of the fax machine."
Many patients go to two or three levels of post-acute care before finding the level that fits their needs, Birmingham says, often because they don’t go to the right place the first time. The IHN system will make a difference, she predicts, "because the discharge planner will have a workflow tool, and the patient is matched to the provider based on needs and availability. Discharge planners also will have more time to work with the complex patient to develop a more precise discharge plan."
Response to the idea has been phenomenal, Birmingham adds. "There is communication only when there is a piece of information and discharge planners don’t have to wait for a phone call. I call it the virtual discharge plan.’ Payers are also very excited about the workflow tool, since it will allow more real-time information and collaboration with hospital-based staff and post-acute providers."
[For additional information on Integrated Health Networks, contact Ruth Fisk at (617) 630-1335 or [email protected] or Jackie Birmingham at (617) 290-3365 or [email protected].]
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