Increasing our Understanding of Long Stay Patients: Results of a One Year Study Rami Cherra, MHA, Manager Business Operations & Karen Nelson, MSW, MBA, Executive Director, Social Work and Case Management Stanford Health Care, Palo Alto, California Background: •
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Discharge Disposition
143
Located in Palo Alto California on the campus of Stanford University, Stanford Healthcare is a 477 bed acute care teaching hospital with several outpatient and ambulatory care locations.
63
41 40 35 32
The presence of Long LOS patients (>30 days) reduces access for patients needing care.
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Long stays in hospital are costly and place patients at risk of becoming deconditioned and/or acquiring hospital related infections
23
4. Daily tracking and distribution of list of patients in target group (>30 day LOS) 9
8
5
4
3
3
2
MEDICARE
1 Year Survival
Deceased within 1 year
High psychosocial complexity found in Long LOS patients
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Lack of alignment and coordination between disciplines can mean unrealistic options are pursued
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Team fatigue in the face of complex and difficult cases
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Overcrowding may lead to prioritization of less complex discharges which can be achieved faster
26%
74%
Lack of understanding of Long LOS patient characteristics
Method: Age Group Distribution
Total number of patients reviewed: 506 Length of Stay
140 122
41-50
51-60
51
32 61-70
24
12
71-80
81-90
11
59
8. Assignment of relief staff (when available) to focus on highly complex cases Year over Year Impact 2015-2018 LOS>30 Day Average by Month Target: <25 per day
26% of patients were deceased within one year suggesting the need for Goals of Care conversations proactively
40
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Payer source was not the barrier it was expected to be.
30
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Median LOS was 40 days
25
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The most common discharge destination was Home!
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20 15
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Highest number of patients were in the age group 61-70
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Largest patient group by service line was Cardiac Surgery followed by Psychiatry. Targeted education, feedback and interventions with these teams helps align treatment goals
10 5
Jan
Feb
Mar
Apr
May
2015
June
2016
July
2017
Aug
Sept
Oct
Nov
Dec
2018
18-30
31-40
41-50
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Average Number of Long LOS patients per day FY 18 = 24.7
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Improved capacity by 1825 bed days over the year 2017-2018
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Using ALOS of 5 days, 400 additional patients had access to care
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Savings for one insurer alone > $22M
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Decreased ED boarding times due to improved access to inpatient beds
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Enhanced interprofessional collaboration and improved alignment on discharge plans for Long LOS patients
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53
8
91-100 101-264
PRIVATE INSURANCE
Impact:
A retrospective case review of all Long LOS patients (>30 days LOS) admitted over a one year period (March 2017- 2018) was conducted
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MEDI-CAL
Discussion: •
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30-40
5. Escalations to Administration to address institutional/professional barriers
7. Stronger role by Social Work and Spiritual Care to support decision making and address patient/caregiver distress
Root Causes:
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3. Identification of most realistic plan for patient and barriers to implementation
6. Case conference to allow for a “deep dive” in highly complex cases
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268
2. Target set for < 25 Long LOS patients per day in house
172 142
Problem or Gap:
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1. Weekly meeting to review Long LOS patients attended by Case Management, Clinical Nutrition, Rehab, Spiritual Care, CNS and/or physician
192
95
The Department of Social Work and Case Management has 175 full and part time staff and includes Case Managers, Social Workers and Support Liaisons
Strategies to Reduce Long LOS:
Payer Source
51-60
61-70
71-80
17
2
81-90
91-100
“Effective interprofessional collaboration promotes the active participation of each discipline in patient care, where all disciplines are working together and fully engaging patients and those who support them” (Tomasik, 2015)