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Reducing LOS is another important goal
A new preadmission program at the University of California (UC) Davis Health System is building a stronger link between hospital and physician’s office and identifying issues — much earlier in the process — issues that might affect length of stay (LOS). In addition to reducing LOS, the initiative is aimed at increasing patient and physician satisfaction, as well as heightening physician awareness, says Karen Warne, RN, manager for patient services and transfer center.
As an academic medical center and regional referral center with a large proportion of its population either nonfunded or underfunded, she notes, UC Davis gets patients who are "the sickest of the sick and the most complex of the complex."
"If we are going to improve efficiency and use of resources, we have the best opportunity to do this with our scheduled admissions," Warne explains. "We thought if we could move the energy spent once the patient is in bed, where nurses look at unidentified needs, to [a time in advance of] scheduled admissions, there would be some opportunity to work with patients proactively to identify the kinds of things they will need for a safe discharge."
"It can be as simple as understanding that the patient lives in a rural area that may be serviced in a limited way by home health," she adds, "or as complex as a patient who’s homeless and normally lives under a bridge who will need intravenous antibiotics after discharge."
The patient in question might be, for example, an 80-year-old widow who lives alone, is independent, but is going to have surgery that will require not just a funding source, but family support or resources, Warne says. "Has the family been contacted? Has she been able to make arrangements [for care after discharge]? If not, what resources are available?" Contacted before admission, before she’s in post-surgical pain, Warne points out, the patient is in a better position to be a participant in her own care plan.
Although no additional dollars were allocated for the program’s startup in the fall of 2003, Warne says, she was allowed to designate Kori Pilkington, RN, one of the hospital’s utilization review/discharge planning nurses, to take the new position of preadmission nurse. "My goal is to demonstrate her value," Warne says. "A physician might be deciding to admit a patient for what really would [more appropriately] be an outpatient work-up, and Kori will be able to talk with the physician, have our physician reviewer look at the case, and a decision might be made to handle it in a more cost-effective way."
It won’t take many cases of deferring elective procedures found not to be medically necessary in the acute setting, or where the patient avoided a prolonged hospital stay because discharge services were arranged in advance, to justify funds for the program, Warne suggests.
To identify patients who might be at risk for longer lengths of stay, she says, Pilkington telephones patients to ask about their post-discharge plans and their perception of what their post-discharge needs will be. She also reviews available medical records, and may speak with the physician or clinic staff. When her assessment is complete, a copy of her notes goes to the discharge planner who will have the case, as well as into the medical record, Warne adds.
Some of the clinics associated with UC Davis have collaborated with Pilkington to develop a questionnaire that patients, with a nurse’s help if needed, can fill out in advance of their hospital stay, she says. The questionnaire, which includes 10 questions designed to help determine if the patient will need assistance or another level of care after discharge, then is faxed to the preadmission nurse. (See questionnaire.)
The questionnaire addresses issues as simple as whether the patient has transportation from the hospital or as potentially complicated as whether the patient is a caregiver. "It’s not unusual to find there is a developmentally disabled adult child at home and now the patient, who is the caregiver, has to go to a lower level of care before going home," Warne notes. In one case, she says, clinic personnel assumed a patient would have help after discharge from the hospital because they knew she had a daughter. "It turned out the lady had told her daughter, Go ahead and take your vacation to Europe — it’s a good time because I’m going to be laid up.’" Another time, Warne says, a patient who lived in a trailer with no electricity asked about transportation and was told by a person at the clinic, "Oh, the discharge planner will take care of that."
"These are the kinds of things we’re hoping to identify early on, shift some of the workload forward and improve communication between the outpatient and the inpatient settings," she adds. It’s my observation that we operate in silos. We are working to improve the transition of care across the continuum."
In the case of the latter patient, Warne explains, Pilkington’s assessment revealed that while a church group had arranged to take the person to the hospital, nothing had been planned regarding post-discharge transportation. She was able to help him contact the church to set up the return trip. Without Pilkington’s intervention, Warne notes, the discharge planner ultimately would have taken care of the problem, but the patient’s discharge would have been delayed while transportation was arranged.
Another case involved a patient who was coming from a locked psychiatric facility to have surgery at the hospital, and the assumption was that the person would return to the same facility, she says. When the preadmission nurse called to confirm this, however, she learned that personnel at the psychiatric facility planned to discharge the patient, assuming they would not be able to meet his post-discharge needs. "By [Pilkington] coming on the case early on," Warne says, "she was able to communicate with the [psychiatric patient’s] conservator, identify the post-discharge needs with the surgeon, and get a nurse specialist and the psychiatric facility together to discuss the case."
"They were able to come up with a discharge destination before the patient was admitted," she notes. What otherwise might have happened, Warne says, is that hospital personnel would have assumed he was going back to the psych facility. By the time they found out differently and were able to arrange post-discharge care, she adds, much time and energy would have been expended as the patient remained in the hospital. "It takes weeks, sometimes months, to find medical-psychiatric beds," Warne says.
In the case of another psych patient — this one coming to the hospital for cancer treatment — Pilkington discovered that the person’s family was making arrangements to move him closer to them, she says. As a result, the hospital was able to transfer care to the physician in that area who would be following the patient’s long-term care. "[The preadmission initiative] is making sure all the pieces are considered, breaking down silos by creating a flow of communication, and being able to offer expertise on some of the things the typical nurse or physician may not know," Warne adds.
Part of increasing physician awareness, she notes, is educating physicians so they are considering "non-medical things," such as funding issues and resource issues, that will affect the use of medical resources. Pilkington, meanwhile, says one of the most enjoyable parts of her job has been interacting with the mostly elderly patients as she tries to identify their needs. "A lot of them are delightful to talk with," she says, and appreciative of being contacted. "An orthopedic patient who was going to have a spinal fusion — a 79-year-old widow — was so thrilled. She said, I am so happy you called — I didn’t realize UC Davis cares about me.’"
Tracking tool on the way
Although evidence of the new program’s success is anecdotal at present, UC Davis is developing a tracking tool that will determine outcomes more precisely, Warne says. "[The tracking tool] is a mechanism to gather data to identify what educational initiatives we might need to consider with clinics or physicians, what the problem areas in the health system are regarding decision making in our use of resources, and hopefully, to identify patients who might benefit from having an assessment made prior to hospitalization."
In using the tool, Warne explains, the preadmission nurse will fill out an intake form that documents the outcome of her interventions and fax it into a database. (See intake form.) Except for the narrative information in the "comments" part of the form, she adds, the data will fall into the various fields of the database. "This will provide data to support the outcomes of this new program, as well as identify areas that will benefit from process improvement," she adds.
The preadmission nurse will indicate whether the patient has met InterQual criteria, used to determine the appropriateness of the admission, Warne notes. She adds, however, that the InterQual outcome is used only as a screening guideline and is not the final decision. InterQual is a clinical decision support tool produced by McKesson Health Solutions in Newton, MA. If the case doesn’t meet the standardized criteria, she says, it is bumped up to a physician reviewer, who makes the final decision. "We’ll be collecting date of admission and medical record number and hope to match that with registration data to see if we’re noticing a difference in overall LOS, patient satisfaction, and reimbursement," Warne says.
[Editor’s note: Karen Warne can be reached at (916) 734-4907 or at firstname.lastname@example.org.]