Case Management Teams Expediting Discharges to Create Hospital Capacity
Whether it is the weather, natural disaster, or a significant event that creates a need for bed capacity, knowing which patients can be discharged today and tomorrow, along with discharging them is paramount.
The goal is to find out who can be safely discharged today and potentially discharged tomorrow. While reviewing the potential discharges for tomorrow, determine if any of those patients are candidates to go today. The determination is made in concert with the attending physician and the required needs of the patient for a safe early transition to the next level of care. The mantra for the entire team becomes Tomorrow Today. By implementing the mantra, the planning for patient progression becomes smoother and less chaotic when beds are at a premium. Ultimately the mantra represents three activities:
Discharge patients planned for today;
Determine which patients could safely discharge a day earlier, today; and
Anticipate those patients that can go tomorrow and start making those arrangements today.
Repeat this daily until the need subsides. Below are some pointers to assist in accomplishing that task.
1. Discuss the issue with the chief medical officer or medical director including Tomorrow Today. Specifically, ask them to notify the physicians of the need to expedite discharges. Typically, the CMO or medical director can send house-wide text messages and/or emails to the attending physicians explaining the situation along with their request.
2. Ensure the unit nurse managers and RNs are informed and understand the circumstances by engaging in a conversation with nursing leadership. (If the hospital operates a discharge lounge, now is the time to liberally utilize it.)
3. Bring your leadership team and physician advisor(s) together as soon as possible. Create a mini command center for the case management department. Speak in one voice. This should be the director or senior manager who can respond to the hospitalwide command center or nursing office.
a. Review the situation along with the work to be accomplished, early safe discharges and transitions to the next level of care. It is important that everyone knows that discharges are the priority. The conversation with the case management leadership should minimally include these topics:
The purpose and how to implement the mantra of Tomorrow Today with the frontline team.
The teams need to understand and be able to implement the CDC guidelines relating to discharging COVID-19 patients, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html. Take a few minutes to review with your leadership team so they can amply educate the frontline teams.
The benefits of dividing up case management tasks among the frontline team. For instance, a person or group of people do initial assessments or screenings while others work on transitioning patients.
When it is an “all hands on deck”, there is value of “borrowing” from the utilization management team.
The role and focus of each case management leadership will play during this event. (See below for description.)
b. Ask your leadership team to educate and update their team on the need for early discharges. They can do this via huddling, emails, and/or texts. Encourage the frontline team to review Tomorrow Today during their treatment team meetings or discussion with physicians and other treatment team meetings.
c. Postpone or delay nonessential meetings for all team members.
d. Do not forget the CM/SW team in the ED. During this time, it is essential to strictly apply medical necessity. Encourage the ED team to make referrals to community providers and agencies. Sometimes it is beneficial to ask a CM supervisor to go to the ED. Implementing this activity offers support for the team and may minimize inappropriate admissions.
4. Involve physician advisors.
a. Request the physician advisors to review ICU patients for possible "movers" to the general units.
b. Enlist the physician advisors for peer to peer conversations when a CM or SW is experiencing resistance from an attending.
c. If you do not have a physician advisor, either ask the CMO/medical director for assistance or call upon a senior attending to assist you.
5. Notify partner (high volume referred) post-acute facilities and other vendors (e.g., home health, ambulance services, etc.) of the hospital's current circumstances. Daily communication with frequently utilized vendors is beneficial. It will help them plan and be more successful in meeting the hospital’s needs.
a. Ask them for assistance and support.
b. Verify their ability to take patients earlier in the day and their current bed availability. Pass this information along to the CMs and SWs.
6. Recruit the frontline CMs and SWs to have discussions with the attending physicians about the patients' ability to discharge early either during treatment team meetings if they occur in the morning. If the meetings are later in the day, ask the team to talk with the physicians before the meetings. These are good opportunities to share the mantra with the entire treatment team.
7. Task the CMs and/or SWs with:
a. Developing a list of patients (names, room numbers, and units) who can safely discharge today and who can potentially go tomorrow following the mantra.
b. Updating the discharge date information in the medical record or EHR as soon as possible. Consider giving your team a "due time" for the information to be entered (so you can pull the data). There will be exceptions, that is to be expected. The objective is to get the majority of information on discharges anticipated today and tomorrow.
8. Run reports or collect the information from the EHR late morning and late afternoon. If reports are not accessible, ask the frontline teams to call, email, or send the information via secure texts to a designated leader. Start compiling the data to share it with the hospital executives or nursing office. Knowing the volume and location of discharges will assist the nursing office in capacity planning. Also, it will indicate areas of possible hot spots where discharge barriers may need mitigating for the frontline team or your leadership team.
9. During this process, your leadership team needs to round on the units assisting with the discharges (and prioritizing) , e.g., calling for ambulances, scheduling ambulances and transportation for tomorrow, notifying family members, talking with patients, making referrals, obtaining authorizations, giving out IMM letters, etc. This is an appropriate time for the case management leadership team to provide any situational updates, eliminate barriers to discharing patients, and offer emotional support to the frontline team.
10. Recognize the members of your team, nursing, and medical staff for their efforts and successes. This is hard work, and it is not the norm.
11. Repeat the process as necessary.
Case Management Leadership Team creating mini command.