Beyond the Pandemic Part 2

Strategies to bend hospital utilization curves

There can be no silos between the emergency room, inpatient units, SNFs and home care. Communication and collaboration are needed as hospitals adjust to the new post pandemic realities. The utilization review process must begin prior to admission and extend beyond discharge in order for the entire process to run smoothly and allow for effective deployment of resources. Promoting high quality care relies on continuity to prevent extra days in the hospital and readmissions, which can be associated with complications such as hospital acquired infections and patient safety events.

There are multiple factors and steps to consider in building a system of best practices in rightsizing length of stay (LOS) and care. Strategies
should begin with pre-admission planning, continue during inpatient management, and extend through post-discharge care.

PRE-ADMISSION:
ER management, elective procedure scheduling, and bed flow

Emergency room flow:
The sooner and more efficiently a patient gets admitted, if appropriate, in the proper type of bed, the quicker they can get treated and discharged. “With improved patient flow, patients experience lower morbidity and mortality, and report higher satisfaction.” ²

Actions:

• • Streamline processes to eliminate unnecessary wait and waste. Hospitals are full of inefficient processes – just ask any patient how many times he or she is asked the same question by different providers or ask an ED nurse how many phone calls are needed to reach an inpatient nurse. These repetitive actions take time, and wasting time on non-value-added activities distracts you from more useful tasks^.2
  • Early assessment in an ER visit is essential. Whether a patient meets criteria for admission using InterQual, MCG or other admission tools, as well as what type of bed/level of care they will need, assessment should begin early.
  • Reduce performance variability. The nature of being human is that we don’t all do things at the same rate. But from a care delivery perspective, variation needs to be reduced and mitigated as much as possible. Reigning in outliers when it comes to performance — whether related to lab/radiology turnaround time, time to see new patients, or time to assess a patient and make a disposition —will go a long way in improving overall throughput.²
  • Employ demand-to-capacity staffing based on both volume and acuity. Determining staffing based on hourly patient arrivals alone is ineffective because that one number fails to fully capture patient acuity. Obviously, a sprained ankle takes much less time and fewer resources than a critical care case, but if you’re only counting patient volume, you’re overlooking half of the demand component. In addition to acuity, factors to consider when making staffing decisions include emergency severity index triage criteria, evaluation and management billing codes and facility billing codes.
  • Maintain excellent communication with admitting clinicians and bed board to smooth the process and avoid delays.

Census and bed management; operating room schedule adjustments

Actions:

• Analyze historical patient volume and admission type data to predict the number and distribution of beds you will need for smooth and correct level of patient care. Put algorithms in place to triage patients to appropriate level of care and integrate surge history to adjust numbers.
• “Optimizing the elective surgery schedule with respect to recovery time yields a flatter inpatient census. Forecast the volume and case mix of surgeries together with the associated recovery time per case and apply lean manufacturing techniques combined with an optimization engine to build surgery templates that avoid spikes in the downstream census.”³
• Space out surgical scheduling. Spreading elective OR cases across the week — also known as surgical smoothing — reduces competition between the ED and OR for inpatient beds, reduces ED crowding and improves OR utilization.²

INPATIENT MANAGEMENT

Assess patient needs and risk factors early.

Actions:

• At the time of admission consider factors such as age, prior independence, preexisting medical conditions, medication complexity, behavioral health status including cognitive functioning, social, or financial situations.
• Based on these factors the team should identify and escalate the discussion of barriers to discharge and work to address each one.
• Institute complex care rounds engaging care managers and social workers to assist in addressing patient’s unique discharge needs.
• UpToDate has several articles that address important areas of concern.
• UpToDate comprehensive geriatric assessment
• UpToDate Hospital Care - Older Adults

Discharge planning starts on admission.

Actions:

• Assessment of expected clinical course, clinical and psychosocial factors that impact post discharge needs begin also on day one.
• Identification, documentation, and communication of the expected date of discharge is essential. Care plan should be orchestrated to progress the patient condition to meet the desired date of discharge.
• Setting discharge expectations and understanding needs of the patient and their designated support system(caretakers) are critical. No eleventh-hour notifications that it’s time for discharge.
• Active and early mobilization ensures readiness for safe discharge.
• Proactive daily care including team huddles around care needs and interdisciplinary rounds to discuss patient’s expected date of discharge, needs as identified on admission as well as those evolving during hospitalization paired with tangible actions plans to remove barriers to discharge.
• Make sure all needed measures in place the day before anticipated discharge: home health, equipment, transportation, medication reconciliation, prescriptions, patient instruction (preferably discussed with patient), transfer forms for ECF, follow up appointments.
• Encourage providers to make early morning rounds and/or verbal discharge orders if appropriate.

DAILY DISCHARGE ASSESSMENT CHECKLIST

• Target discharge day
• Current medical condition and stability
  1. Are they on target or is an adjustment needed? (use InterQual, MCG etc.)
• Disposition plan - where are they going post hospitalization?
  1. Will an extended care facility (ECF) or a 24-hour caregiver be needed?
  2. Be realistic: Consider prior condition and support systems to help determine disposition needs.
  3. If ECF needed, determine payment eligibility early and family preferences and resources.
• Discharge needs, equipment and services: home health nurse, aide, caretaker, therapy, oxygen, walkers, wheelchairs etc.
• Schedule follow up appointments

BALANCE BETWEEN INPATIENT AND OUTPATIENT TESTING

Expand hours of operation for certain procedures and tests³

Actions:

• Testing may need to be expanded into evenings and weekend to speed discharge.
• Examples: Stress testing, GI lab, radiology, and non-urgent procedures such as lines, peg tubes, etc. may need to be
  done during nontraditional work hours.³
• Prioritize tests and procedures for patients ready to be discharged; transition non-urgent tests and procedures from inpatient to outpatient setting.

Actions:

• Patients ready for discharge pending one final test or procedure should be considered for priority if clinically feasible without impacting quality of care for other patients.
• Test and procedures that can be deferred to post discharge without a negative clinical impact should be considered for scheduling as outpatient.³

Keys to addressing post-discharge care

Changes in the post-acute patterns of care show a reduction in skilled nursing facility admissions and a rise in home health providers. Understanding how these changes are impacting hospitalizations will allow utilization review teams and treating physicians to make optimal use of these services to decompress the hospital on both sides of an acute admission through facilitating proper discharges and preventing avoidable readmissions.

• Changes in patterns of SNF care.
• SNF volumes have not returned to pre-pandemic levels, which could be due to the hit they took during the pandemic and reluctance of patients to utilize care facilities due to COVID.
• SNF patients tend to be more acute. Data from CarePort, a care coordination platform, shows patients discharged to SNFs compared to 2019 had:
  • Shorter hospital stays: A SNF patient’s average hospital LOS is a half day shorter than in 2019.
  • Increased comorbidity: The average comorbidity score of a SNF patient has increased by 9% since 2019.
  • Fewer elective surgery patients: A 15% decrease in SNF patients under the diagnostic category “Musculoskeletal System & Connective Tissue” indicates those undergoing elective surgery for broken bones or joint replacements are now less likely to recover in a SNF.4
• SNF Levels Decline as Home Health Rises.
• “At the onset of the pandemic in the U.S. … SNF referrals declined by 40%; home health referrals by 30%; and hospice referrals by ~25%.
• Home health referral volumes returned to normal levels by July 2020 …. by March 2021, referrals reached 116% of 2019 totals. …..as of May 2021 referrals to the SNF setting still hadn’t reached 2019 levels.” 4
• This rise in home health care services with the stagnation of SNF volumes may be related to patients and their families preferring home to a facility in the shadow of the pandemic.

With these changes, the complexity of hospital discharge increases as more patients need to be in the hospital longer to be stable enough to be discharged home. At the same time, SNF processes must be restructured to address patient acuity. Being aware of these barriers early in planning facilitates flow.

POST-ACUTE CARE PLANNING

Preventing readmissions and avoidable days
Actions:

• Use tools such as the LACE score to identify readmission risk and address them.⁵
• Discharge appointments should be set up prior to leaving the hospital.
• Clear instruction of what to look out for and what to do if any undesirable event or symptoms occur.
• Explain diagnosis, what happened in the hospital and follow up plan to patient and their caretakers avoiding medical jargon and using teach back.
• Discharge summary sent with a good hand off to primary care provider.
• Post discharge follow-up phone calls to check on status.
• Use care coordinators and case managers to monitor and mentor patients post discharge. Identifying early any clinical changes, educational and access needs or compliance issues that would increase the risk of decompensation and readmission.
• Leverage the use of telehealth to improve access and monitoring. According to Viziant, telehealth “is expected to resume its climb and by 2032 account for 27% of all evaluation and management visits.”⁶

Steps to prevent medication adverse events: key causes of readmission

• Provide clear medication reconciliation document; review with patient and caretakers is critical.
• Involve pharmacist if available and discuss potential adverse effects of medications.
• Check for drug interactions.
• Utilize home medication administration tools: pill boxes, reminders, checking of home to remove discontinued drugs.

"Virtual health visits have a strong path forward over the next decade, particularly for specialties where frequent touchpoints support positive outcomes,” McDowell (Maddie McDowell, MD, FAAP, senior principal and medical director of quality and strategy for Sg2) said. “While scalability for
care at home is difficult, care redesign efforts can leverage remote-patient monitoring and artificial intelligence to improve patient monitoring, drive operational efficiencies and lower costs by shifting patients to the home setting, when appropriate.⁶

CONCLUSION

Understanding the changes that came about because of the pandemic, their root causes and impact on hospitals is critical in building strategies that apply all along the continuum of care. Not only do hospitals need to intensify the use of past tools, but also adjust their approach to meet the patterns that have developed post pandemic due to pent-up needs and delayed care. Focusing more intensely on patient flow, post-acute care planning and management along with leveraging newly built telehealth capacities may break up the bottle neck and bend the utilization curve.

All source information in the downloadable document.