Every morning at 8 a.m., a multidisciplinary team at Wayne Memorial Hospital in Honesdale, Pa., a rural pocket of about 5,000 people about 30 miles northeast of Scranton, gathers to discuss discharge planning. Representatives from social services, home health, nursing, physical therapy, pharmacy, and the HM group attend the meeting. Each stakeholder weighs in, listens to others, and voices concerns when applicable.
“We go through each patient in the morning, briefly, and go through the plan so that when there’s a discharge coming, everybody is on the same page and can try to get everything organized,” says Louis O’Boyle, DO, FACP, FHM, medical director of Advanced Inpatient Medicine, the hospitalist program contracted by Wayne Memorial, which has 98 acute-care beds. “The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.”
Better bed management is a new mantra for hospitalists nationwide, because fewer open beds means fewer dollars for both the physician and the hospital. Better bed management also means improved patient satisfaction scores, as most patients would rather be at home (and those scores in the coming years will factor into Medicare reimbursement). And better bed management means reduced backlogs across the hospital, particularly “boarders” in the ED.
“The pressure really is on the hospital for a number of reasons,” says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. “In terms of reimbursement, the sooner they can get a patient out of the hospital, it opens bed space for patients in the emergency department. It eases up bottlenecks because the patient in the ED may not need the bed that is being opened, but they may need an ICU bed, and the ICU patient is stable enough to be transferred to that medical bed that you’re opening up. So it’s a domino effect, and it certainly helps with creating a better flow within the hospital.”
It sounds simple, of course: Discharge inpatients early in the day and fill that bed with another patient, akin to a busy restaurant flipping tables to reduce the line stretching out the front door. The more customers, the more money made—both for the restaurant (i.e. hospital) and the servers (i.e. providers). And the less potential customers wait, the happier they are with their service.
But adding new beds, at nearly $1 million per bed inclusive of the space, infrastructure, and technology, is unacceptable math for most U.S. hospitals struggling to make ends meet in a tough economy.1 By contrast, an aggressive bed-management approach creates virtual bed capacity that creates more revenue-generating opportunities without those costs. And as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys tie patient satisfaction more directly to compensation, the more attention that will be focused on the discharge, as it will be the last process the patient experiences, and the one they likely will remember the most.
So if everyone agrees that discharging inpatients earlier in the day is a good idea, what’s the holdup? Interviews with more than a half-dozen hospitalists show a handful of factors that are present in all hospitals, large and small, academic and community:
- Downstream complications. HM is only one piece of the discharge puzzle. Hospitalists might be ready to discharge, but without that last test, or the ability to reach a pharmacist, the process slows. Even when discharge is complete, the room needs to be cleared and cleaned.
- Rounding protocols. Hospital-ists intuitively round on the sickest patients first, but that time-honored tradition has the byproduct of pushing those patients most likely to be sent home to the end of the line, automatically delaying discharges.
- Shift flexibility. Many hospitalist groups have morning shifts that begin at 8 a.m. Given the time it takes to craft discharge orders and deal with inevitable wrinkles in the process, that almost guarantees discharges will be pushed to later in the day.
- Hospital infrastructure. Insti-tutional bed management begins at the top, with a commitment across departments that discharge procedures are a shared priority. Without such across-the-board buy-in, the best hospitalists can do is fight against the tide. For example, a room could be vacated at 10 a.m., but housekeeping isn’t notified (or prepared) to clean the room for two hours because there is no institutional procedure in place to govern that decision.