• A Team Approach to Reducing Complex Discharge Delays at Denver Health

    Jan 24, 2012

    A cross-disciplinary team meets weekly to help patients overcome complex barriers to going home or being transferred to another facility. That effort has contributed to a drop in the hospital's average length of stay-and an annual return of $2 million to $3 million.

    Every week, Denver Health puts together a list of 10 to 30 patients who should be getting discharged or transferred-but can't for a variety of complicated reasons. Many of the patients require a long-term care or skilled nursing facility, but the patient's complex medical regime or lack of insurance prevents the transfer. Other patients have psychosocial or legal issues, such as a mental illness or lack of a legal guardian, that make discharges difficult.

    Since 2008, a cross-disciplinary team at Denver Health-the Complex Discharge Committee-has been identifying novel approaches to ensure safe discharges for these complicated cases.

    For example, several years ago Denver Health collaborated with the Denver Probate Court to install a video conferencing system-at the hospital's expense-so frail, legally incompetent patients could participate in guardianship hearings from the hospital instead of a courtroom. These patients usually do not have a next of kin who is willing or suitable to serve as a guardian to make decisions about their care or placement.

    "Based on this experience and other executive-level interventions, we brought together a team-the C-suite, social workers, nurses, and other staff-that understood these barriers and could make innovative decisions to facilitate transition to the next level of care for these patients," says Thomas MacKenzie, MD, chief quality officer, Denver Health, a 477-bed safety net hospital in Denver.

    The committee's work has helped lower the hospital's average length of stay (LOS) for adult nonobstetric patients by a full day-from five to four days-in three years time. "We think the return on reducing LOS has been about $2 million to $3 million annually," says MacKenzie.

    Assessing Patients' Needs

    Fourteen hospital leaders are involved in this cross-disciplinary approach to reducing discharge delays.

    • CFO
    • COO
    • Chief medical officer
    • Chief nursing officer
    • Chief quality officer
    • Chief government relations officer
    • General counsel
    • Assistant general counsel
    • Medical director of behavioral health
    • Director of social work
    • Clinical social worker
    • Supervisor from the physical therapy department
    • Director of utilization management
    • Medical attending physician

    The committee meets every Wednesday morning to review a list of patients who have been in the hospital for more than 10 days and focuses discussion on the 10 to 30 patients who have the potential to be discharged or transferred.

    The committee then assesses the resources needed to move the patients on the list to the next level of care, says Darlene Ebert, general counsel. Common solutions include the following:

    • Reviewing the patient's medications to see if changes in route, dose, or type might facilitate a safe discharge home or approval for transfer to another facility
    • Weaning patients off ventilators or other complex medical regimens so they can be cared for in post-acute care settings
    • Working with an accepting facility in another region or state to transport the patient back to his or her community to receive care either in a primary care clinic or appropriate facility
    • Locating relatives, or proxy-decision makers, to further the patient's care and ensure a smooth, timely discharge
    • Making arrangements with long-term care facilities to provide transitional care for uninsured patients whose Medicaid eligibility is pending

    "We collect information from the nurses who are taking care of these patients, the medical team, utilization management, social work, physical therapy, and occupational therapy so we can make the best disposition decisions," says MacKenzie.

    Investing in Solutions

    Sometimes Denver Health must invest funds to help ensure discharges or transfers. For example, the committee sent a Spanish-speaking clinician to accompany a patient who was hospitalized with a traumatic brain injury back to his family in Central America. The clinician brought a wheelchair and other equipment that the patient's family would need to take care of him at home.

    "It made financial sense for us because the bed was being occupied, and it made long-term sense for the patient because he had family who wanted to care for him at home but were unable to travel to the U.S.," says MacKenzie.

    MacKenzie says the work of the Complex Discharge Committee would be less successful without the commitment and involvement of the hospital's C-suite. "Many of our successful interventions would not have worked without the insight of individuals like our CFO, our chief medical officer, or our general counsel," he says.

    Interviewed for this article:

    Thomas MacKenzie, MD, is chief quality officer, Denver Health, Denver (thomas.mackenzie@dhha.org).

    Darlene Ebert is general counsel, Denver Health (darlene.ebert@dhha.org).

    For more about this initiative, see a related blog piece by Darlene Ebert.