Faced with increasing delays in patient discharges, leaders at one Bon Secours Mercy Health hospital in Virginia took a hard look at ways to address the challenge.
The changes developed at Bon Secours — St. Mary's Hospital in Richmond resulted in a significant drop in the amount of time patients admitted through the emergency department were hospitalized and led to a renewed focus on sending more patients who require additional care to their own homes to recover, rather than to skilled nursing facilities.
"It's all about serving all patients to the best of our ability," said Dr. Leanne Yanni, chief medical officer at St. Mary's Hospital.
"We have to address those efficiency issues that may impact the quality of care," she added. "We have to be good stewards of our resources and make sure that when home is possible we make that a reality, especially when that's the goal of our patients and families. We want to make sure our care is aligned with their goals."
Delays in patient discharges create bottlenecks throughout the health care system, affecting both efficiency and quality of care, she said. Logjams put a strain on caregivers, reducing their ability to care for others and leaving fewer beds available for other patients who need them. Plus, longer stays in the hospital can result in lengthier recovery periods for patients and higher chances for developing a complicating infection.
A national issue
According to the American Hospital Association, the average hospital stay increased 19% overall in 2022 compared with pre-pandemic levels, and increased 24% for patients discharged to post-acute care, such as skilled nursing or rehabilitation facilities.
Staffing shortages at nursing homes and other long-term care facilities, delays in insurance approval, and other factors exacerbate the problem, Yanni said.
Bon Secours — St. Mary's Hospital colleagues, from left, Krista Davidson, director of rehab services; Dr. Leanne Yanni, chief medical officer; Andrea K. Williams, manager of care coordination; and Dr. Muktak Mathur, medical director of the Vituity hospitalist program, worked together to rethink and improve the Richmond, Virginia, hospital's discharge process.
Yanni was instrumental in developing and implementing the changes at St. Mary's and sharing the results with other hospitals within and outside the Bon Secours system. Cincinnati-based Bon Secours Mercy Health is the fifth largest Catholic health care system in the nation, with 48 hospitals and more than 60,000 employees.
Yanni worked on the discharge project in conjunction with earning her master's degree in health care management from Harvard T.H. Chan School of Public Health. She said discharge delays meant patients ready for release from St. Mary's to skilled nursing care ended up staying in the hospital for two to seven days longer than was medically necessary.
"It was clear we had a high percentage of patients going to skilled nursing facilities and their length of stay in the hospital was twice as high" as those who weren't, Yanni said. Because of those high numbers, it seemed like tackling that specific bottleneck would have the greatest impact hospital-wide.
A unified approach
Creating an interdisciplinary team of frontline workers helped hospital leadership identify three ways to improve patient outcomes and promote quicker discharges.
The first was early evaluation of patients' functional status and mobility, a key to understanding whether they could be discharged home with in-home nursing and therapy services.
Second was a widespread educational effort among staff to help remove barriers to home discharge, such as mixed messaging from caregivers, and to eliminate skilled nursing as the default next step. Discharging to skilled nursing facilities is a multistep process, including insurance authorizations, that commonly results in discharge delays.
Third was standardizing the discharge process, by creating a centralized report so that a care management leader could remove barriers and ensure progression through the multistep process. A discharge disposition tool also was created to support team collaboration and decision-making in daily interdisciplinary rounds. The tool provides a guide for the team — physicians, nurses, therapists, care managers — to align on the safest and most productive discharge recommendation for patients and their family.
The changes have reduced the percentage of patients discharging to skilled nursing from more than 14% to less than 11%, Yanni said, and significantly decreased the number of medically unnecessary days in a hospital bed.
Many moving parts
Yanni said sending a patient home to a familiar environment, with the appropriate resources such as physical therapy, is not only better for the patient, but thousands of dollars less expensive.
Coordinated discharge planning is key, she said. And if a safe discharge and effective home is not possible, only then should caregivers look to a discharge facility.
"It's a complicated process with many moving parts," she said.
"Our goal here is to achieve high quality care for the patients and families we serve, especially in transitions out of the hospital, while serving as good stewards of very limited health care resources."