Discharge Planning From
Day One
South King Care Transitions Conference
Des Moines, Washington
June 5, 2014
• Qualis Health is one of the nation’s leading healthcare
consulting organizations, partnering with our clients across the
country to improve care for millions of Americans every day
• Serving as the Medicare Quality Improvement Organization
(QIO) for Idaho and Washington
• QIOs: the largest federal network dedicated to improving
health quality at the community level
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Healthcare organizations have come to
recognize that making decisions
regarding next levels of care and giving
discharge instructions to patients in the
last few hours before their discharge is
not effective…
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Today’s Objectives
In this session we will hear how two
healthcare systems took this concern to
heart and recognized the need to start
discharge planning as soon as patients are
admitted.
Participants will gain insight into their journeys
to improve this situation and explore ways in
which these techniques might be
incorporated into their settings.
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Delayed Discharge Planning
• Does not allow the next care providers to
obtain information or be adequately
prepared to receive the patient
• Patients and caregivers are not ready for
their transitions
• Lengthy, detailed instructions as patients
are heading out the door often are missed
or confused
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Influencing Factors
• Shorter hospital lengths of stay
• Rapid work-up of patients with multiple
tests and procedures
• Multiple providers interacting with patients
• Patients being discharged “sicker” than in
the past
• Components of the discharge more
complex
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Health Literacy
The degree to which individuals have
the capacity to obtain, process, and
understand basic health information
and services needed to make
appropriate health decisions
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Factors Limiting Health Literacy
•
•
•
•
•
•
Challenged by sickness
Feelings of vulnerability
Too much medical jargon
Too many pieces of information
Very stressful situation
Too much happening at once
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Sound like the last hour before a
patient is discharged?
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Community Panel
Stephanie Mudd RN MSM CCM
Manager
Care Management TG/AH/MBCH
Tacoma General Hospital
MultiCare Health System
Tacoma, WA
Kim Barwell, RN MN ACM
System Manager
Care Management
Franciscan Health System
Tacoma, WA
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Stephanie Mudd RN MSM CCM
Manager
Care Management
TG/AH/MBCH
Tacoma General Hospital
MultiCare Health System
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Achieving Smooth Patient
Flow: Discharge by Noon
June 5, 2014
Methodology & Strategies
• Lean
• Multidisciplinary Team
• Daily Huddle and Rounds
Our Multi-disciplinary Team
MIS Physician
Care Managers
Nursing
Pharmacist
Therapy
Dietary
Chaplain
Social Work
Service
Quality
Culture/
People
Cost
Throughput
Target
1st 26 Weeks of 2014
ACTUAL DISCHARGES ______________
DATE:___________________
Room MRN EDD MD CM RN DC
ORDER
TIME
WHERE/HOW
ACTUAL
DC TIME
REASONS FOR DISCHARGE DELAY
*Reason for late or delayed written
DC order
(after 1000)
*Reason for pt leaving after 1200 if
order written
before 1000
Check the following that are true.
Points
Age 80 or older
1
No funding source
1
More than 4 Chronic Conditions
1
Active Behavioral / psychiatric health issue
1
Six or more prescribed medications
1
Two or more hospitalizations within the past 6 months
1
Readmitted within 30 days
1
Inadequate support system
1
Low health literacy
Documented history of non adherence to the therapeutic
regimen
1
Require assistance with ADL's
1
Substance / ETOH abuse
1
CM / MSW / Physician determination
6
1
Take the sum of the points and enter the total
Score
Low
0 to 2
Medium
2 to 4
High
5 to 6
Intensive
above 6
Care Management Strategies for Risk of Readmissions
Intensive Risk
High Risk
1. Care Conference
1. Care Conference Recommended
2. Evaluate SNF vs HH
2. Evaluate SNF vs HH
3. Referrals
3. Referrals to consider
Palliative
Palliative
MSW
MSW
Pharmacy Med Rec
Community Referrals
Community Referrals
HF Clinic, RCCP, COPD Focus, Pulmonary Clinic etc
4. Follow up appoitment with PCP
Goal: Appointment within 2 days
HF Clinic, RCCP, COPD Focus, Pulmonary Clinic etc
4. Follow up appointment made with PCP
Goal: Appointment within 2 to 4 days
5. CM Discharge Summary Completed
5. CM Discharge Summary Completed
Medium Risk
Low Risk
1. SNF vs HH
1. SNF vs HH
2. Community Referrals
2. Community Referrals
HF Clinic, RCCP, COPD Focus, Pulmonary Clinic etc
3. Follow up appointment made by patient unless cognitivaly impaired
Goal : Appointment within 5-7 day
4. CM Discharge Summary suggested
HF Clinic, RCCP, COPD Focus, Pulmonary Clinic etc
3. PCP appointment made by patient
Goal: Appointment within 7 - 10 days
4. CM No Discharge Summary Required
What are the key
take away messages?
• It is all about the patient
• Safety
• Discharge planning begins at
admission
• Open & frequent communication
• Collaboration between disciplines
Average Patient Discharge Time by TG Unit: 6R
6R
draft
Target
6R Trend
4:00 PM
3:00 PM
2:00 PM
6R
5R
1:00 PM
12:00 PM
target: 12:00p
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
11:00 AM
better performance
Source: QlikView-Inpatient Performance
A great Hockey player skates to
where the puck is going to be.
Wayne Gretzky
Thank you!
References
• Abraham, J., & Reddy, M.C. (2010). Challenges to interdepartmental coordination of patient transfers: A workflow
perspective. International Journal of Medical Informatics,
79(2), 112-122.
• Optimizing patient flow: Moving patients smoothly through
acute care settings. IHI Innovation series white paper,
2003.
• Martinson, J. (2014). Improving care transitions: The Pierce
County pilot project. WSMA Foundation for Health Care
Improvement.
• Young, Terry, McCLean. (2009). Some challenges facing
LEAN THINKING in healthcare. International Journal for
Quality in Healthcare, 21(5), 309-310.
• An Evidence-Based Review and Training Resource on
Smooth Patient Flow. (2012). University of Tasmania.
Kim Barwell, RN MN ACM
System Manager
Care Management
Franciscan Health System
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Discussion and Questions
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Next Steps
• Discussion regarding what is currently taking
place in your organization to begin discharging
planning earlier in the care process
• Consider changes that might be made to
encourage earlier planning
• Contact others to obtain information on “best
practices”
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Thanks Again to our Panel
Stephanie Mudd RN MSM CCM
Manager,
Care Management TG/AH/MBCH
Tacoma General Hospital
MultiCare Health System
Tacoma, WA
Kim Barwell, RN MN ACM
System Manager,
Care Management
Franciscan Health System
Tacoma, WA
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Questions?
Carol Higgins, OTR (Ret.), CPHQ
Qualis Health
carolh@qualishealth.org
206-288-2454
For more information:
www.QualisHealthMedicare.org/Transitions
This material was prepared by Qualis Health, the Medicare Quality Improvement Organization for Idaho and Washington, under a contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. WA-C8-QH-1417-06-14
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