Many hospitals struggle to discharge patients into post-acute care in a timely manner, but at Bon Secours Richmond (Va.) Health, three small operational changes dropped their mean length of stay from 2.21 to 1.95 days.
An overwhelming majority of emergency department physicians across the country say they have experienced boarding times in their facilities exceeding 24 hours, according to a 2022 survey from the American College of Emergency Physicians. Discharge delays due to a lack of beds in nursing homes and other long-term care facilities are a key factor driving boarding challenges.
Bon Secours Richmond was no different. To address the problem, leadership looked inward to see what processes could be improved in hospitals.
"We found several delays with discharging to skilled nursing facilities," Peter Charvat, MD, chief clinical officer of Bon Secours Richmond, told Becker's. "First of all, patients lacked understanding of skilled nursing and why they might need that care instead of going home. Second, we weren't identifying which patients were eligible for skilled nursing facility discharge early enough. And third, we had variable messaging to patients. Physicians, nurses, therapy people and other providers all see the patient a little different. One might look at a patient's functional status while others consider social determinants of health. This led to patients getting different opinions about where they should be discharged to."
The first change Bon Secours Richmond made was to eliminate patient confusion. The system started planning for discharge the moment the patient was admitted. Hospitalists documented the level of function, or prior level of function and compared it to the patient's current level of function at admission. That information was used to determine if the patient was likely to need to discharge to a skilled nursing facility. Each day, a list is created of which recently admitted patients may need skilled nursing discharge.
The second change was the creation of a tool that outlines specific parameters for discharging patients to inpatient rehab, skilled nursing and home. The system also created a post-acute resource guide that can help patients no matter where they go. Care teams then held regular meetings to discuss the best discharge plan. This allowed clinicians to start the discharge conversation with patients and family early, and start the process for insurance company authorization early.
"So early identification, early consensus, early messaging to the patient and family," Dr. Charvat said.
The last change came as a result of the collaborations — hospitalists refocused on the question, "Why not home?" Often, clinicians jump to skilled nursing as a good option but home may be the better option, Dr. Charvat said.
Refocusing on this question made its own impact on discharge delays. While speaking early to patients helped prevent length of stay, team collaboration and focusing on home reduced the percentage of patients discharging to skilled nursing from 14% to less than 12%.
The pilot changes launched last year on the medical surgical unit at one hospital. They were so successful that it was rolled out in the latter half of last year to all med-surg units at Bon Secour Richmond Health's hospitals.
"At the end of the day, it's just that diligent focus early on where we expect the patient to go," Dr. Charvat said. "I can't emphasize enough the importance of having those conversations early with patients and family."