Practice Economics

The Earlier, the Better


 

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.”

Listen to AnnMarie Papp

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:

Listen to Ken Simone
  • 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.

“It’s harder than you think,” Dr. O’Boyle admits. “There are always extraneous factors that can delay the hospitalists from getting [discharges] done.”

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Bed Management Listen to AnnMarie Papp

Figure 1. 2008-2009 hospital bed capacity by country

Bed Management

Early-day discharge is just one pathway to improve “patient flow” and, therefore, bed management, according to a recent editorial in Health Affairs jointly penned by executives from the Institute for Healthcare Optimization in Newton, Mass., and the Institute for Healthcare Improvement in Cambridge, Mass.1

Other techniques are:

  • Reducing length of stay (LOS): Hospitalists have long focused on keeping patient stays at a minimum, although many researchers have argued that LOS can only be reduced to a point. Quality and patient safety issues in the Affordable Care Act might actually increase LOS, as hospitalists and other physicians work to reduce 30-day readmissions by ensuring everything is done right the first time.
  • Expanding capacity: At an estimated cost of $1 million to add one new bed to a hospital, it is simply unlikely that institutions will be in a fiscal position to add physical beds in the next few years.
  • Increasing staff: “Here again,” the authors state flatly, “pressures on hospital systems and operating margins make it unlikely that hospitals will dramatically increase their payrolls.”

No Consensus

Although a variety of techniques can help improve early day discharge, all have hurdles. Two of the most common suggestions are geographic rounding and discharge lounges. A third is the active bed-management (ABM) model that hospitalist Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, wrote about in the Annals of Internal Medicine in December 2008.2

Geographic rounding, also dubbed unit-based setups, can help improve bed management because all participants are co-located; however, the gains likely are not enough to motivate an institution to implement the model without demonstrated improvements to other systems as well, says John Nelson, MD, FACP, MHM, cofounder and past president of SHM and a principal in the practice management firm Nelson Flores Hospital Medicine Consultants.

Discharge lounges—areas usually administered by a nurse and billed as a place for patients to gather after they’ve been formally discharged but before they have arranged a ride to physically leave the hospital—have been adopted by many hospitals. Dr. Simone and others question the liability issues associated with keeping discharged patients under the watch of hospital staff and also wonder whether the setup can have a negative impact on patient satisfaction. (For more on discharge lounges, check out “Solution of Problem,” at www.the-hospitalist.org.)

If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.

—David Bachman, MD, senior medical director for transitions of care, MaineHealth Clinical Integration, Portland, Maine

David Bachman, MD, senior medical director for transitions of care at MaineHealth Clinical Integration in Portland, Maine, and a former hospital administrator in New England, sees hospitalists as a lynchpin to the discharge process, but he also urges them to get the hospital to see them as “change agents” who need institutional support to make significant improvements.

“You’re trying to run cases through and it’s all dependent on downstream activity,” Dr. Bachman says. “If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.”

Ideas to Chew On

Mitchell Wilson, MD, SFHM, chief medical officer for Eagle Hospital Physicians in Atlanta, agrees that reprioritizing physician rounds to encourage discharges would push patients out earlier, but he wants to see more physician assistants and nurse practitioners (PAs and NPs) blended into those rounds. The partnership would be a relatively simple and direct way for physicians to pass off nonclinical or less-intensive duties that afford them more time to focus on discharge planning. A dedicated nurse for HM service and the use of telemedicine could be folded into HM practices to help.

Listen to AnnMarie Papp

Figure 1. 2008-2009 hospital bed capacity by country

Listen to AnnMarie Papp

Figure 2. U.S. hospital bed capacity and costs

Each of the techniques would serve to get patients out earlier on what is arguably the most costly day of their stay. “Hospitals generally lose money on the last day of a patient’s stay,” Dr. Wilson says. “When appropriate from a patient care standpoint, discharging your patient and getting the bed ready for the next patient sooner is definitely an advantage for the hospital, and for the next patient.”

Dr. Bachman says one of the main hurdles to that process is no single provider “has clear responsibility and oversight. … It’s this diffuse responsibility.” That’s where Dr. Howell and colleagues thought ABM would work well. At Hopkins Bayview, hospitalists staffed an active bed-management program that rounded twice daily in ICUs and visited the ED regularly. The hospitalist on the 12-hour shift had no other duties, a luxury that HM pioneer Robert Wachter, MD, MHM, described at the time as “freeing him or her up to act as a full-time air traffic controller for all medical patients.”

The intervention reduced ED throughput for admitted patients by 98 minutes, to 360 minutes from 458 minutes. It also cut the amount of time the ED diverted ambulances because of overcrowding—the so-called “yellow alert”—by 6%, and the amount of time ambulances were diverted due to a lack of ICU beds—“red alert”—by 27%. Dr. Howell, an SHM board member, says the results showed how hospitalists can lead throughput change through institutions but that more work needs to be done to focus on early-day discharge.

“The hospital medicine side may be incentivized for early discharges,” he says, “but the hospital systems may not.”

Dr. Howell pushes for “2-by-10,” shorthand for identifying two patients daily who could be discharged by 10 a.m. because “the ED doesn’t necessarily need more beds for 24 hours. They need more beds early in the day.” But in keeping with the ABM model, Dr. Howell believes fiscal and personnel resources have to be dedicated to the problem to expect results. In the Hopkins Bayview intervention, Dr. Wachter, professor and associate chairman of the Department of Medicine at the University of California at San Francisco, chief of the division of hospital medicine, and chief of the medical service at UCSF Medical Center, estimated the annual costs of ABM at close to $1 million a year, given the likely need for four to six full-time equivalent hospitalists, according to a post on his Wachter’s World blog (www.wachtersworld. com) after the report was published.

One idea Dr. Howell suggests to push earlier discharges is restructuring physician workweeks, setting aside certain days for admission and certain days for follow-ups. If two shifts of follow-up days are scheduled after two days of admissions, it’s likely a hospitalist could follow a patient through their entire stay, he says. “You have to structure the doctor’s day to focus on discharges first,” he adds.

Dr. Howell also believes multidisciplinary rounds are key to earlier discharges. At Wayne Memorial Hospital and other places that have instituted such teams, discharge usually is just one byproduct of a construct ultimately aimed at quality improvement. Wayne Memorial’s Dr. O’Boyle says that since the team approach was initiated in September 2009, the hospital’s LOS has dropped by 0.75 days and patient satisfaction scores have risen about 25%. Those metrics will be key data points in the years to come as discharges and readmissions become tied to reimbursement via healthcare reform (see “Value-Based Purchasing Raises the Stakes,” May 2011).

Dr. Wilson

“One of the biggest factors for readmissions are things like pharmacy errors, and lack of follow-up, and other loose ends that, if you’re in too much of a hurry to get people out and you don’t have the whole team approach and make sure all your I’s are dotted and T’s are crossed, then they have an increased chance of coming back,” Dr. O’Boyle says. “So we focus on patient satisfaction, and we focus on the discharge day and the discharge time to prevent readmissions and to maximize patient satisfaction. That’s the bottom line for the hospital…It’s interesting how the bottom line seems to follow quality.”

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Helpful Hints

1. Hold discharge conferences. Hospitalists can’t determine a patient’s readiness for discharge in a vacuum. Pre-discharge meetings with nurses, case managers, pharmacists, and other health professionals can make sure every stakeholder is working toward the same goal. Consider scheduling conferences the day before discharge to reduce time pressures.

2. Start at admission. The axiom that discharge begins at admission is true for a reason. Dr. Nelson suggests making a habit of forecasting a discharge day in a chart’s order section, not just in the progress report section, to ensure the planned-for date is seen by all parties.

3. Do it today. Putting together discharge notes the night before certainly makes for a longer shift, but it can save valuable time the next morning. Consider cases in which compiling the discharge notes the day before can highlight a final test or procedure that should be ordered. In those instances, waiting until the morning to begin that process would undoubtedly delay the eventual discharge until later in the day.

4. Early birds get the worm. The first shift for HM groups often starts between 8 a.m. and 10 a.m., so consider having a physician start their shift earlier to focus on discharges before rounding and other clinical responsibilities.

Inherent Conflicts?

Early-day discharge actually can be a bad thing in some cases, Dr. Nelson says. Think of a case in which a patient might be ready for discharge in the late evening or during an overnight. To wait until the morning to send that patient home might not be the best approach.

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.

—Louis O’Boyle, DO, FACP, FHM, medical director, Advanced Inpatient Medicine, Honesdale, Pa.

“The place that manages length of stay most efficiently probably has plenty of late-day discharge,” he says.

Another potential conflict getting in the way of early-day discharge is what Dr. Wilson calls “admission competition.” For example, a hospitalist is working on discharge papers early in the morning but is then called away for a consult on an acute-care case in the ED or elsewhere. Each of the duties is important, but conflicting duties leave the hospitalist having to make choices.

“It’s not all straightforward,” Dr. Nelson says.

Emergency Nurses Association President AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, says that collaboration between nurses and physicians is an answer to such competition. Calling the problem a “wrinkle across the system,” Papa says that without hospital administrators taking point and declaring the issue of discharge a priority, little wholesale improvement will be made. Even then, physicians and nurses—as the two main groups interacting with the patient—have to work together, she adds.

“Hospitalists have to partner with nurses,” Papa says, imploring physicians and nurses to work together on discharge decisions. “If the physicians and nurses collaborate on the decision and plans of care for the patients and the care they’re giving them and the discharge instructions, then it’s a win-win for everybody.”

Richard Quinn is a freelance writer based in New Jersey.

Reference

  1. Litvak E, Bisognano M. More patients, less payment: increasing hospital efficiency in the aftermath of health reform. Health Affairs. 2011;30(1): 76-80.
  2. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.

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