'Strategic triad' initiatives help health system cut LOS
'Strategic triad' initiatives help health system cut LOS
Interdisciplinary meetings focus on discharges
UCLA Health System in Los Angeles reduced length of stay and improved patient throughput by using a "strategic triad" of initiatives that includes interdisciplinary rounds, clinical high-risk meetings, and use of escalation to overcome barriers to discharge.
"Capacity issues, unfunded patients, and health care reform provisions have created significant challenges for our health system as well as other healthcare providers today. Our care coordination department undertook this initiative to address these challenges and to train the staff to effectively implement the strategies," says Marcia Colone, PhD, LCSW, system director for care coordination, UCLA Health System. The health system includes Ronald Reagan UCLA Medical Center, UCLA Santa Monica Medical Center, Mattel Children' s Hospital UCLA, and Resnick Neuropsychiatric Hospital UCLA.
Since UCLA began the initiative, the average length of stay at Ronald Reagan Medical Center has dropped by 0.8 day and by 0.5 day at Santa Monica Medical Center. Since the weekly clinical high-risk meetings, which focus on patients with longer-than-average stays, were begun on May 1, 2010, the average long lengths of stay have dropped from 17.2 days to 16.1 days at UCLA Ronald Reagan Medical Center and from 11. 3 days to 10.4 days at UCLA Santa Monica Medical Center.
"We usually are over 95% occupancy. We have to get patients moved through the continuum quickly and safely, and we are always looking for ways to do so," Colone says.
The interdisciplinary team on each medical unit holds rounds on every patient every morning and lightning rounds in the afternoon to discuss patients whose discharge is pending.
Participants in the morning rounds include physicians, nurses, case managers, representatives from ancillary services, and the hospitalist team. They discuss the care plan, the patient's progress in meeting his or her goals, what is to happen that day to meet the goals of the care plan and get the patient ready for the next level of care and any barriers to discharge.
The case manager presents basic information about each patient, including the prior living situation, functional status, payer source, and other pertinent information, then asks each discipline to provide updates, expected length of stay, and expected discharge destination.
For instance, the house staff identify the goals of care, how the patient is responding to treatment, results of tests, clinical care planned for the day, rationale for level of care, and anticipated discharge date. The bedside nurse reports on intensity of service, what is being provided for the patient, and gives a brief rundown on family engagement, patient teaching, the patient's capacity to learn, and activity level. The social worker discusses family engagement and family resources, and sets up a family meeting with the team, or requests financial assistance if needed.
"The interdisciplinary rounds are pivotal in enhancing communication and hand off. We make sure the discussion points are very clear and that everyone understands what we are focusing on. We have developed scripting that helps people stay on track and doesn't allow anyone to deviate into other discussion points," Colone says.
Each of the six medicine services holds lightning rounds with the case manager as the facilitator and focuses on patients who are expected to be discharged the next day. Other participants include physical therapists, social workers, discharge planners, and pharmacists.
The team discusses medical necessity, progress on goals for the day, barriers to meeting the goals, next steps, anticipated discharge, and discharge destination.
During weekly clinical high-risk meetings, the team looks at patients with a length of stay that is greater than one standard deviation above the average length of stay. The one-hour meetings are led by the care coordination manager and attended by case managers and social workers. The team reviews problematic cases and focuses on what the barriers are and develops strategies to address the barriers. When appropriate, the team uses the High Intensity Escalation process to identify real or emerging barriers, interventions attempted and failed, and escalate through the chain of command.
"We take a laser focus on what has to happen and what are the issues. We use escalation when routine strategies have failed, when the patient has been medically ready for discharge for at least a day and the discharge plan is sketchy or seems illogical, and when the case manager or social workers feels that a real barrier is emerging," Colone says.
For instance, if there are avoidable delays because of the physician action or inaction, the case manager or social worker first communicates with the physician, then escalates to the physician advisor for a physician-to-physician discussion, then informs the care coordination manager about what is going on. If the delays are because the patient is reluctant to discharge or doesn't have an adequate support system, the case manager or social worker first talks to the patient and family, then asks the physician to talk to the patient and family, and strategizes with the care coordination manager about the next step.
"High Intensity Escalation isn't second nature. With high caseloads, often interventions are started and paused and focus is lost when the escalation process isn't formalized and integrated into the daily workflow. The escalation process is designed to get the staff focused and helps them understand that the goal is to advance the care plan and discharge the patient safely and that everything in the middle has to be managed," Colone says.
Source
- Marcia Colone, PhD, LCSW, System Director for Care Coordination, UCLA Health System. e-mail: [email protected]
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