Scorecard of red flags helps improve the discharge process
Scorecard of red flags helps improve the discharge process
Tracking data can stem persistent problems
Successful discharge planning is a much more complex process than simply moving patients safely out the door, so it follows that evaluating your discharge planning process also might be a complex proposition. But some experts suggest that keeping an eye on small, easily tracked data can prompt you to red flags before they become persistent problems.
"I think the most important way to know if your discharge planning process is working well is to have some sort of scorecard for it," says Beverly Cunningham , RN, MS, vice president of Clinical Performance Improvement for Medical City Dallas Hospital.
That scorecard can be as simple or as far-reaching as your situation demands, but some obvious and easily tracked statistics can give you a good snapshot of changes to keep an eye on.
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While patient satisfaction is a big factor in determining whether any aspect of care is successful, measurable data and benchmarking can help spot where processes could be improved and patient discharge and movement through the hospital made smoother.
Those include factors such as length of stay, days in intensive care (ICU) and telemetry, number of bed holds in the emergency department (ED), rate of Medicare appeals upheld by the quality improvement organization (QIO) that reviews them, and number of patients who leave the hospital with no services.
"There are five things I track myself, but it could be any number – it dovetails with the discharge planning model you use," explains Toni G. Cesta, PhD, RN, vice president, patient flow optimization, corporate quality management at North Shore-Long Island Jewish Health System in Great Neck, NY.
Check data, review criteria
Cesta says one of the indicators she tracks is the number of discharges who are seen by a case manager or social worker. If the percentage of patients seen by a CM or SW is 32% to 56%, for example, that means half to two-thirds of patients who come into the hospital aren't seen by case management.
"That would be a red flag to me," says Cesta.
A red flag might mean your facility's handling of the discharge process is malfunctioning; or, it might be that the process itself is the problem.
In the case of a high percentage of patients being discharged without seeing a CM or SW, Cesta suggests, "go back and look at your processes."
"Maybe you're using high-risk criteria, and maybe the criteria are too restrictive," she says. "Maybe the type of patients has changed, and maybe you need to look at how, under your model, patients are assessed. If every patient is assessed [under your hospital's model], and you're only hitting 56%, then the problem is something else."
Another factor Cesta measures is the time from admission until the patient is seen.
"The national benchmark is 24 hours, while in some organizations it's 72 hours on a weekend, or even universally 72 hours," she points out. "Obviously, you can track that and see how you do. In some of our facilities, we have 30% of patients taking longer to be seen, and that affects their length of stay and the discharge planning process."
Cunningham monitors the number of patients who meet the "medical necessity" criteria for their stay. If a significant or growing number of patients remain in the hospital even when they aren't meeting the criteria for continued stay, it can be a red flag calling for evaluation.
Wearing out their welcome?
Besides looking at how long patients are staying, Cunningham suggests looking at where they're staying.
"Look at your length of stay for telemetry and ICU days, and train [staff] to benchmark that," she says. "There are not good benchmarks for that, but you can look for a longer length of stay in those units when they're not meeting the criteria."
Cesta says some hospitals might consider a "long" length of stay to be 14 days; in years not too long past, 30 days was considered a long stay.
"The average might be to say '10 days or greater' to define a long length of stay," Cesta suggests. "Then, categorize those patients; how many are acute and appropriately in the hospital? We found that 70% of our patients in the hospital 14 days or longer were acute."
The remaining 30%, non-acute patients, fell into other categories, with discharge issues that could include:
- Patient/family issues, such as the patient or family waiting to select a continuing care facility, or when the family is wrestling over whether to move the patient to a nursing facility or try to care for the patient at home;
- Facility-specific delay, as when a facility is selected but has no bed available;
- Payer issues, as when transfer is delayed pending approval, or awaiting Medicaid application or managed care/continuing care service approval;
- Psychiatric issues, when the patient needs a psychiatric bed but one is unavailable;
- Legal issues, including guardianship questions, or individuals with questionable or no documentation.
"And then there are patients you can't discharge today because you're waiting on the physician to do a consult, or to write discharge orders or a prescription, or waiting for labs, or an MRI or CT, or a stress test, echocardiogram, or for nuclear medicine," Cesta adds. "And family issues as simple as the family member works and can't get by to pick up the patient until late in the day. Or the patient can't leave without a walker, and you're having to wait for the DME [durable medical equipment] delivery."
While each of these might seem specific to each patient, Cesta and Cunningham advise tracking them nonetheless; an inordinate number of one delay or another might suggest re-thinking things such as discharge time (morning vs. afternoon), supplier requests, and communication with family.
"Look at your avoidable days, and ask what they're due to," says Cunningham. "There are four functions of case management: discharge planning, care coordination, utilization management, and resource management. If you're not doing good care coordination, you can't do good discharge planning."
Unfunded patients who are staying longer than medical necessity criteria dictate, she says, are a clear red flag that some discharge planning procedures aren't being applied appropriately.
Discharge with no services: Too little planning?
Cesta says she tracks how many discharges leave the hospital with no services at all. This is a benchmark that's variable based on the hospital, "but it shouldn't be greater than 60% to 70%," she says, meaning that at most, if more than 60%-70% of patients go home with no services, "you might be missing patients."
Of patients leaving with services, it helps to know what services they are going into – home care, sub-acute care, etc.
"It helps with your discharge planning acuity," Cesta points out.
Care coordination is a big factor in good discharge planning, Cunningham says. So if you're hearing complaints from case management staff about consultants, for example, your care coordination is bound to suffer.
Cunningham and Cesta both strongly suggest paying attention to QIO findings in Medicare appeals.
"If you have appeals regarding the second IM [the notification to patients that they're about to be discharged and that they can appeal], and those appeals are being substantiated by the QIO, that would be something you'd need to think about," Cunningham says. "And even if you have appeals that are not substantiated by the QIO, you have to ask yourself, 'How did we get to this point? Did the patient just want to stay longer, or did this happen because we weren't managing it?'"
Finally, Cunningham says, give weight to patient complaints and satisfaction.
Focus groups including patients or families who've had recent hospital stays, including parents of pediatric patients and patients who have had more than one admission, can be tremendous resources for information on how the discharge planning aspect of their case management worked.
"We use a Gallup survey, and we ask them about the discharge planning process and whether they have aftercare services. I think if patients aren't happy with their experience with being discharged, then I think that, too, is a red flag that the process isn't working well."
Sources
For more information, contact:
- Toni Cesta, PhD, RN, FAAN, Vice President, Patient Flow Optimization, North Shore–Long Island Jewish Health System, Great Neck, NY. E-mail: [email protected].
- Beverly Cunningham, RN, MS, Vice President, Clinical Performance Improvement, Medical City Dallas Hospital, Dallas, TX. E-mail: [email protected].
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