Since the beginning of the COVID-19 pandemic, the postacute landscape has been challenged by significant staffing shortages and facility closures (American Healthcare Association/National Center for Assisted Living [AHA/NCAL], n.d.; American Hospital Association, 2022; Schoenberg, 2020). As a result of decreased postacute capacity, patients in acute care hospitals are experiencing prolonged length of stay (LOS), and case managers (CMs) supporting discharge planning are navigating a complicated postacute environment, requiring increased outreach to facilities and engagement of multiple stakeholders (i.e., home health services, behavioral health services, state ombudspersons, etc.). CMs support the Centers for Medicare & Medicaid Services (CMS)-mandated comprehensive discharge planning to ensure a safe transition of care, but the role has evolved to include coordination of care needs (Bourque et al., 2021) to mitigate adverse consequences of inadequate planning (Holland et al., 2017).
Discharge planning directly impacts LOS, throughput, and readmission rates (Chen et al., 2021; Chovanec & Howard, 2021; Holland et al., 2017). One effective strategy used by CMs to improve discharge efficiency is the use of standardized discharge planning decision tools. These tools have been shown to improve discharge efficiency and reduce LOS by supporting a smooth transition for patients from acute care to other facilities or to home with services (Chen et al., 2021; Holland et al., 2017; Moosa & Khoja, 2022).
In an expanding community hospital with an increasing census of medical and surgical patients with complex discharge needs, the project team determined that the current discharge assessment process did not prioritize patients most in need. The Early Screen for Discharge Planning (ESDP) is a decision support tool developed by Holland et al. (2017) that uses readily available data from the electronic health record (EHR). ESDP is used by CMs at the first critical decision point in the discharge planning process to flag patients at risk for complex discharge planning early in their hospital stay and maximize time to organize a multifaceted plan (Holland et al., 2017).
Purpose/Objectives
The objective of this project was to design and implement a modified version of the ESDP to prioritize patients with complex discharge needs and increase CM efficiency, with the primary outcome of decreasing LOS. The project team adapted a previously published ESDP tool to integrate with the institution's EHR to identify patients, who do not require CM support due to a low ESDP, and improve initiation of CM services from admission to initial CM assessment for high-risk patients. Analyses were performed to determine whether the modified ESDP (Brigham and Women's Faulkner Hospital [BWFH] ESDP) adequately identified patients with discharge planning needs. Finally, the BWFH ESDP was implemented with defined intervention and control cohorts to measure impact on LOS.
Project Design/Description
Setting
The setting for this project was a 171-bed Magnet-designated community teaching hospital that is a member of an integrated health care system in the Northeast United States. The case management team consists of a nurse director and seven CMs, each covering 18 patients. Two 36-bed units (each with two CMs) were selected as the intervention and the control cohorts (comprising medical and surgical patients). The project took place over a 90-day intervention period (September 1, 2021, to November 30, 2021), including patients who were admitted Monday through Friday. In calendar year 2021, the organization had 7,825 discharges of which 52%, 29%, 9%, 10% were discharged to home, home with services, skilled nursing facility, and other postacute facilities, respectively.
Ethical Considerations
The project met the health care system's institutional review board criteria as a quality improvement project and determined to be exempt from formal institutional review board review.
Project Design
The project was initiated to address concerns that increasing complexity of patients was requiring increased time to appropriately plan for safe patient discharge. CMs met with their nurse director to establish a formal project team and recognized that any potential practice changes would need to be operationalized without additional resources. The ESDP tool was identified as a strategy to prioritize the most complex patients. A member of the project team consulted with other organizations that had implemented ESDP to learn about their experiences. A proposal was developed for an ESDP pilot and presented to key stakeholders, including senior leadership.
Intervention Design
The project was designed as a prospective controlled study. The ESDP score is based on four criteria: self-rated walking limitation, age, prior living status, and the Rankin Disability Scale (Holland et al., 2017). A high ESDP score (>=10) indicates patients who would benefit from early discharge planning, whereas those with a low ESDP score (<10) are unlikely to have discharge planning needs. The admission nursing assessment included the first three components of the ESDP but not the Rankin Scale. A decision was made to substitute the Modified Rankin Disability Scale with the BWFH Mobility Level of Assist (MLA) scale present within the institution's version of Epic (see Figure 1), as the nursing informatics team identified that the MLA captured variables comparable with the Rankin Scale. The BWFH Modified ESDP decision support tool was integrated into the organization's electronic patient assessment flow sheet (see Figure 2).
Implementation Into CM Practice
CMs assigned to the intervention cohort started their day by reviewing the ESDP score for new admissions. Patients with an ESDP score of 10 and greater were prioritized to receive the usual CM evaluation. For patients with an ESDP score of less than 10, validated by chart review, the CM documented this assessment in the EHR. An ESDP charting shortcut (smart phrase) was developed by CMs to document that a chart review was conducted, and that the patient's clinical course would be followed during daily interdisciplinary rounds. This documentation indicated that the patient did not meet criteria for further CM support at that time, but that CM would be available as indicated.
For patients with an ESDP score of less than 10 who had identified discharge planning needs, either through chart review or from interdisciplinary rounds, the CMs completed a full assessment, and the usual admission CM note was documented. The CMs participated in daily interdisciplinary rounds to ensure that patients with unanticipated discharge planning needs are captured.
Auditing
To determine the ability of the ESDP tool to correctly identify patients' discharge planning needs, independent audits were conducted by two CMs, who were members of the project team but not involved in the implementation. The auditors conducted an independent chart review to determine a standard ESDP score (inclusive of the original Rankin Scale) for each patient, which was compared with the BWFH ESDP score (inclusive of the MLA). Discrepancies were identified and auditors wrote a detailed comment for each discrepancy.
Statistical Analyses
Demographic and descriptive analyses are presented as counts and percentages. LOS analyses were conducted utilizing internal databases categorizing patients by service and unit. R (version 4.1.2) software was used to conduct statistical analysis, including [chi]2 test for categorical variables (demographic variables) and t test for continuous variables (LOS).
Results
The project included a total patient population of 718: 376 in the intervention and 342 in the control cohorts. There were no significant demographic differences between the two cohorts for age, gender, ethnicity, race, or primary language spoken (see Table 1).
Objective 1: Determine Ability of the Modified ESDP to Correctly Identify Patients With Discharge Planning Needs
CMs wanted to ensure that the revised process was reliable and that patients were appropriately categorized (needing ongoing CM support or not). Two designated CMs, who did not work on the intervention unit, completed 370 chart audits comparing the standard ESDP score with the modified ESDP to determine the percentage of discrepancy between the scores. Of the 370 chart audits completed, 14% (n = 50) revealed a discrepancy (see Table 2). Of the 50 audited charts with a discrepancy, 10% (n = 35) of the patients had a modified ESDP score of 10 and greater (vs. standard ESDP score of <10) and were automatically assessed by CM. Only 4% (n = 15) of patients with a modified ESDP score of less than 10 (standard ESDP score of >=10) did not receive a CM assessment on admission. CMs completed an assessment for 10 of these patients after admission, following discussions at daily interdisciplinary rounds and/or after the CM completed a chart review. In all cases, the patients had unique situations that warranted additional support (e.g., travel outside the United States). For the remaining five patients, an additional chart review was conducted, which revealed that the modified ESDP score was appropriate on admission. Three patients had a change in condition during hospitalization, identified during interdisciplinary rounds. One patient was waiting for psychiatric placement and did not require postdischarge services. One patient received CM services as part of a surgical recovery pathway.
Objective 2: Improve Resource Efficiency of Case Management Services
The second objective was to determine whether implementation of the modified ESDP improved efficiency of CM services. CMs identified the percentage of patients who screened out for services within 24 hr of admission using the ESDP. On the intervention unit, 53.5% (n = 201) of patients had an ESDP score of less than 10 and were screened out of requiring a full CM discharge planning needs assessment (see Table 3). CMs reported that they were able to allocate the extra time (53.5% workload change) in their schedule to the patients with complex discharge planning needs.
Objective 3: Decrease LOS
The third objective was to determine whether the implementation of ESDP was associated with a decreased LOS. The team observed a decreased LOS on the intervention unit, unadjusted and adjusted for case mix index (CMI). CMS (n.d.) uses a hospital's CMI to determine reimbursement rates for Medicare and Medicaid beneficiaries. CMI "reflects the diversity, complexity, and severity of patient illnesses treated" (Definitive Healthcare, 2023, para 1) with a higher CMI indicating that the organization treats a greater number of "complex, resource-intensive patients" (Definitive Healthcare, 2023, para 2). Over the project period, the average LOS on the intervention unit was 5.43 compared with 5.96 on the control unit. For the same time period, the CMI-adjusted LOS was lower on the intervention unit (3.91) than on the control unit (4.46), with a trend toward statistical significance (p = .083; see Figure 3). We postulate that although the patients on the intervention unit had a slightly higher CMI, indicating that they may have been more medically complex than patients on the control unit, their discharge process was more efficient, leading to a trend toward decreased LOS.
Limitations
The primary limitations of this project include the small sample size and single community-hospital setting, limiting generalizability to other settings. Applicability to a large, tertiary care hospital with greater breadth of clinical conditions is unclear. Another limitation was that the creation of the modified ESDP was necessary due to lack of availability of the Rankin Scale within our institution's version of the EHR. However, the modified score performed similarly to the standard score, with a 14% rate of discrepancy; only 4% had a modified score of less than 10 compared with standard ESDP score of 10 and greater and ultimately received CM support due to identification during daily rounds. In addition, it was not possible to randomize the intervention, so there may be unidentified confounders, though both cohorts were relatively balanced. Finally, the intervention was implemented during a time of postacute staffing shortages, leading to CM time constraints; it is possible that the efficiency and LOS impacts could be attenuated by improved postacute capacity.
Discussion
In this project, the team implemented a modified ESDP score that substituted the Rankin disability scale with an MLA assessment and found that it performed comparably with the standard ESDP in identifying low-risk patients, not requiring CM services. Implementation of the modified ESDP led to 53.5% of patients screening out of CM services and increased time spent on complex patients, associated with a 0.55-day LOS reduction approaching statistical significance. This project was novel as it involved implementation of a screening tool during a period of postacute capacity challenges, providing an opportunity to maximize the efficiency of CMs, and examines its impact on a meaningful outcome, LOS.
Although there is limited research to date, other researchers have demonstrated that early screening discharge tools can improve clinical outcomes. Chen et al. (2021) found that screening patients with community-acquired pneumonia for complex medical conditions, utilization, family structure, activities of daily living, home supports, and socioeconomic factors to initiate discharge planning led to 7-day statistically significant reduction in LOS. Moosa and Khoja (2022) implemented an early multidisciplinary round discharge planning checklist, which resulted in a 1.4-day LOS reduction. These studies support the use of early screening tools to support discharge, but further evolution is needed to ensure incorporation into inpatient CM workflows.
CMs are expected to be knowledgeable about all aspects of care coordination, including complex rules and regulations (such as the CMS Conditions of Participation), actively engaging patients in the process, while being fiscally responsible with limited resources (McLaughlin Davis & Morley, 2022). Notably, as the population ages and develops more complex medical, socioeconomic conditions, the workload of CMs will continue to increase, and, therefore, more sophisticated tools are needed to augment the abilities of this critical workforce.
Nationally, we are facing an unprecedented capacity crisis, due to a myriad of factors-deferred care due to COVID-19, increased demand for medical and surgical care, and a "great resignation" of health care staffing across all role types (Schoenberg, 2022). Postacute facilities have been among the hardest hit, leading to months long delays for some patients to be discharged (AHA/NCAL, 2022). The implications of the acute hospital and postacute capacity crises are multifold and additive, ultimately resulting in patients' progression of care being delayed potentially leading to worse clinical outcomes. As such, innovative strategies are needed to improve the delivery of CM services provided and ensure that adequate attention is given to those with the most complex of discharge plans. Use of early discharge planning that leverages screening tools can ensure timely, appropriate transition from the hospital to the postacute care setting, while maintaining patient's goals of care and treatment preferences (CMS, 2019).
Implications for Case Management Practice
The findings from this project have direct implications for CM practice. CMs were able to adapt their workflow to review the ESDP scores to prioritize patients for assessment. Concerns about patients being "missed" were addressed through the audit process with validation that daily interdisciplinary rounds were successful in ensuring that patients with evolving conditions were consistently identified in follow-up. Organizations considering implementation of a modified ESDP should identify specific patients who may benefit from CM assessment regardless of a low ESDP score, due to standardized care pathways. The implementation of a modified ESDP is a successful, valid, and cost-effective strategy that can identify patients with complex discharge planning needs early in the hospitalization.
Conclusion
The modified ESDP tool represents an evolution of an early screening tool and workflow adaptation that offers the opportunity to improve CM efficiency and LOS. Further study is needed to understand its generalizability across diverse settings, but it is practical and feasible to implement across a broad population. Given the current acute and postacute capacity challenges and the complexities of managing discharge planning with often limited staffing, we advocate for further innovative approaches to optimize case management care delivery.
References