In this episode, Maria Miranda, Director of Emerging Payment Models and Meliza Weiner, Clinical Review Nurse at BESLER, discuss strategies for managing a patient’s length of stay.
Michael Passanante: Hi, this is Mike Passanante. Welcome back to the Hospital Finance Podcast.
Today, I’m joined by Meliza Weiner, RN who is a clinical review nurse at Besler Consulting. And I’m also joined by Maria Miranda who is the Director of Emerging Payment Models also at Besler Consulting.
Welcome back to the show.
Maria Miranda: Thank you, Mike.
Meliza Weiner: Thank you.
Mike: So Meliza and Maria have joined me today to help us talk about and weed through managing length of stay to reduce in-patient cost in a hospital setting. So Meliza, I’m going to turn to you first.
Is reduced length of stay still important in today’s healthcare environment?
Meliza: Oh, absolutely, Mike, it is. It is important for healthcare organizations to consider looking at their length of stay—and not just reducing it, but also looking to make sure that the patient receives quality care and is safely discharged or transitioned into the next level of care such as maybe going to a post-acute provider like a skilled nursing facility or rehab or even using home health.
In essence, reducing length of stay should not be looked at as just solidifying an organization’s margin in today’s payment paradigm or model as some of us know it, but it should also help an organization strategize, enhance and streamline their processes to ensure that efficient, quality care is delivered.
Mike: Maria, with so much focused being placed on reducing re-admissions, where does length of stay come into that discussion?
Maria: So Mike, Meliza definitely hit the nail on the head with that one. Appropriate length of stay is important in reducing re-admissions and lowering the overall cost of an episode.
If a patient is stable enough for discharge or transfer, then any extension of a hospital stay is unnecessary and increases the chances of adverse events to occur which can further prolong the stay.
You really want the patient in the most appropriate level of care as well, so that whatever treatment or therapies must begin, do so in the most appropriate setting.
Being home is also very helpful to the mental well-being. And all of this translates to higher patient satisfaction.
Having said that, the last thing you want is a patient going home too soon or not having the resources necessary once they get there to follow the discharge protocols necessary to avoid a problem and possibly a re-admission to the hospital or an ED visit.
If a patient with other chronic condition is discharged to a SNF, for example, and that SNF is not equipped to handle the patient’s other conditions and does not have the right resources available on a timely basis for that patient, the chances of an unplanned ED visit or a subsequent admission to a hospital increases.
Mike: And Meliza, on a previous podcast, we’ve talked about patient satisfaction. What is the relationship between length of stay and patient satisfaction?
Meliza: Well, you see, Mike, what needs to be understood here is that length of stay is influenced by all members of the healthcare team and the patient. So basically, a patient-centered, efficient, well-coordinated team approach to patient care leads to a reduced length of stay and that the patient’s expectations are met.
If the expectations are met, it increases the patient’s satisfaction and the overall perception of care.
Mike: Maria, what are some reasons that patients are kept in-house longer than necessary?
Maria: Mike, there’s probably a laundry list. There are many, many reasons, some of which I did touch on in my last response.
The best case scenario for the patient is to be discharged to home if possible or to another facility that is equipped to care for them. If planning is not done timely and those resources aren’t available, the patient may end up staying in the hospital longer than is optimal.
Again, we’re talking about the optimal length of stay for the patient. That’s why it’s important to get this planning started as soon as possible and to have a good back-up plan as well.
Even if the plan all along basically is to discharge the patient to home, complications can arise during the stay that can change matters. There are social issues that can hold things up—for example, if there’s a disagreement about where the patient will go once they get discharged, are they going back to their home or are they possibly going to stay with a son or a daughter temporarily while they recover, do they need home-care, but it might take a couple of days to get that set up. It’s really important to start that planning.
And we’ve talked about this before as well. It used to be that that planning started when the patient was admitted to the hospital. In the case of these Episode Payment Models, at least for CJR, that planning needs to start way before the hospital visit.
With AMI and CABG, that’s a little different because those tend to be unplanned.
So, in some cases, the patient might just be waiting for a discharge order or for a final test needed to clear them. There are a lot of reasons, a lot of processes which is why the patient might be sitting there even though they’re ready to go home.
Mike: Meliza, for hospitals looking to reduce their length of stay, what are some of the strategies that they can implement?
Meliza: Well, Mike, reducing length of stay has been at the forefront of many healthcare organizations. And to be honest with you, it is a challenge and an ongoing process… but not impossible.
I think first is having engagement by every department that will affect this length of stay initiative—from senior leadership to management to physicians to nursing to clinical departments like pharmacy and physical therapy and non-clinical departments like admissions, registration and transport.
Having the buy-in of these departments will help make your length of stay initiative be successful.
Then get representations from some key area departments to develop strategies on how to improve length of stay.
For example, if you’re thinking of establishing daily inter-disciplinary rounds to ensure well-coordinated care for your patients, you would need the input from departments like physical therapy and dietary, respiratory, case management, social work, pharmacy, nursing and physicians.
And finally, address any challenges or barriers presented as it comes such as, “What is the best time to do the rounds so every department is in attendance? Is it eight o’clock? Is it nine o’clock?” Those are the challenges that they would need to face.
Mike: Meliza, in your personal experience, have you found that some strategies work better than others?
Meliza: Well, what I have found that works best is engaging the departments and/or disciplines that will affect the efficient coordination of care of the patient. I have found that inter-disciplinary rounds work if you have key disciplines in attendance and engaged such as case management to facilitate a safe discharge plan, social work to address any social or potential social issues, physical therapy, dietary, physicians and nursing.
What have I also found beneficial is engaging and meeting with the post-acute provider leaders and liaison maybe monthly or at least quarterly. These are your skilled nursing facilities, your rehabs, home health and hospice. This will enhance communication, identify and address any opportunities for improvement. Their engagement helps facilitate a smooth, safe and efficient transition.
And of course, you can’t forget, you have to involve the patient in the plan of care. That is essential.
Mike: Maria, turning back to you… can having a preset discharge time and place help or hurt with a hospital’s efforts to reduce length of stay.
Maria: So Mike, I’m going to say that it hurts. This is an example of a hospital policy that’s just getting in the way.
So, we’ve talked about patient-centered care which is a relatively newer concept. Back when these hospital policies were put in place, hospitals weren’t necessarily focusing on patient-centered care, but they’re looking at their own processes and what’s easier for their employees and for doing their day-to-day.
And for many years, hospitals have had this policy where all of their patients are discharged at noon, for example. So even if the patient is all set and ready to go in the evening, there’s no process in place to facilitate the discharge until the next morning.
Think about the bottleneck that this creates if everyone that needs to go home is being discharged at the same time.
So Meliza mentioned how important it is to give discharge instructions. But if you have several patients all being discharged at the same time, that puts a lot of pressure and time-constraints.
So, many hospital shave actually changed this policy and will now discharge patients throughout the day.
And this makes sense on several fronts. First of all, patients are admitted at all hours of the day. All patients are admitted at three o’clock say. So having a patient that’s taking up a bed until the next morning doesn’t make a whole lot of sense if you’ve got a packed emergency room or if you’ve got patients waiting for a bed.
Additionally, going back to this whole patient-centered process, discharging in the evening might be easier for some family members who would otherwise have to make special arrangements during the day. Possibly, they might have to take time off of work to bring their family member to the hospital.
I think a change to discharging when ready is a pretty good example of patient-centered care.
Mike: Can providing data and education to team members help in managing length of stay?
Maria: Well, I love data. I think all data is helpful as long as it’s used appropriately and there’s transparency. And most importantly, Mike, it’s got to be correct.
Physicians will use the data that you provide to modify behavior as long as they trust that the data is accurate and meaningful.
And one of the ways that you go about doing this is making sure that the data that you’re providing is risk-stratified because all doctors believe that their patients are the sickest and their cases are the most challenging. So, any comparison between them and their peers needs to take that into consideration.
So, the benefit of looking at these episodes is that you can look at everything that happened to a patient for the full 90 days, not just for the time that the patient was in the hospital. And using all of the data that’s available on these episodes, you can drill down to such things as the anchor hospital’s length of stay, the length of stay at the SNF or the rehab, re-admissions, you name it.
So, you have enough data and you can start making some correlations. But sometimes, it’s difficult because there are so many other factors that can impact the episode including the patient’s age and other complications such as chronic issues.
So, managing the length of stay can be different depending on the type of episode. Going back to our Episode Payment Models, for CJR, patients tend to have a very high post-acute expenses due to a long length of stay at the SNF or at rehab. So, reducing the hospital length of stay for those cases is not as important as keeping them out of the SNF or making sure that they’re not in the SNF as long as they are.
Whereas for cardiac cases, it’s expected that the bulk of that expenses is actually going to be in the in-patient anchor admission and in re-admissions. So it’s more important to manage the cost there and to keep them from coming back to the hospital.
Mike: Meliza and Maria, thanks for stopping by and helping us understand more about how to manage length of stay.
Maria: Great! Thank you.
Meliza: Thank you.