As BWH continues to deliver the highest quality of care and manages the most complex medical cases in the region, it is still charged with the challenge of reducing
length of stay (LOS). This, to all clinicians, is a difficult though necessary challenge.
FY 02 closed with an average LOS of 5.40 days—a marked improvement from
5.47 days in FY 01. The cumulative effort of physicians and other members of patient care teams has led to this decrease and made possible the opening of virtual beds across the institution as BWH continues to grow designated service lines. However, there is still room for improvement. In the beginning months of this fiscal year, average LOS at BWH is between 5.5 and 5.6 days; whereas the budget is set at 5.44 days.
The plan to further reduce LOS at BWH includes continuous data analysis and reporting; further improvement of patient care team communication; minimizing facility-related delays; restructuring BWH’s clinical pathway program; hospital-wide clinical management initiatives; and implementation of a Tower regionalization plan. While much work on these components of the LOS plan are in early stages, well underway are a redesigned care coordination model and efforts to minimize alternative care-related delays.
1. New Care Coordination Model
Driven by director Joanne Hogan, RN, MS, the new model allows for every patient to have a care coordinator to monitor and facilitate his or her care on a daily basis. No longer will care coordinators only be involved with the most complex patient cases. Aggressive recruitment over the last ten months has resulted in one care coordinator for every 20 to 25 patients, which is a marked improvement from the former one to 35 ratio. Since January, 13 additional positions were added to the original 24-member care coordination team.
“A more involved and larger league of care coordinators means that the patients’ continuum of care is more seamless,” said Hogan. “In addition to positively impacting BWH’s LOS, the new model offers patients and their families a consistent advocate during their hospital stay.”
The role of the care coordinator at BWH has evolved under the new model to include and allow for the following:
- lower Care Coordination RN : patient ratios and reorganization of service teams;
- early, initial patient assessments to determine appropriate discharge plans;
- direct personal communication with attendings;
- daily consultations with nursing staff;
- daily team rounds with housestaff to coordinate care and discharge planning for all patients;
- conduct and document post-discharge follow-up calls; and
- track Managed Care Appropriateness Protocol (MCAP) and pathway variance data to review utilization of hospital resources for patients served within a particular service.
2. Minimizing Alternative Care-related Delays
BWH has a four-pronged approach to address delays associated with transferring patients to alternative care facilities.
- To more swiftly transfer acute rehabilitation patients appropriately, BWH
is working to establish a BWH physician director in the vent unit at Youville
Hospital and Rehabilitation Center.
- To enhance the care provided to our patients who require a skilled nursing facility, BWH has created a value transfer program with the Boston Center. The program, which involves reimbursement from BWH to the Boston Center has involved 61 patients (primarily Medicaid and unfunded care) from December 2001 to October 2002 and has decreased average LOS for this patient group from 27 to 10 days.
- BWH has aimed to access Partners Home Care services to the fullest extent. With an increased focus on home care, BWH has been able to make approximately 3,000 patient referrals to Partners Home Care in FY 02. Focused home care program development is underway for BWH orthopedic, obstetrics and thoracic patients. BWH has referred more than 8,000 discharges in FY 02 to home care services rather than an extended stay in the hospital or extended care facilities.
- To enable care coordinators to access short and long-term care services for patients, BWH has begun to use an information system called 4NEXT. This IS tool will support more efficient referral of patients to extended care facilities, representing approximately 5,000 BWH discharges in FY 02.
“The reason we continue to fine tune existing opportunities to reduce LOS and investigate new ones is to create more virtual bed capacity. In order to support our continued growth and patient care goals as an institution, LOS reduction is pivotal to all service lines,” said Michael Gustafson, MD, MBA, executive director, Center for Clinical Excellence.
Submit LOS reduction suggestions to Gustafson at mgustafson@partners.org or to your division chief or department chair.