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Hospitals are now being financially penalized for unnecessary readmissions — at the same time, bed turnover ratio is a key indicator of productivity for an inpatient department. That’s not to suggest that patients have or should be discharged before it’s clinically safe to do so. Rather, it’s that the various pressures inherent in the current healthcare climate present a real and practical challenge to the balance between providing excellent, thorough care and ensuring your hospital stays well into the black. With that in mind, here’s a quick primer on what you need to know, and some high-level steps for decreasing length of stay (LOS) in the face of a changing reimbursement and regulatory climate.
Defining the two-midnight rule
Until just a few years ago, the Centers for Medicare and Medicaid Services (CMS) had provided little guidance to hospitals on how to determine whether a particular patient should be treated on an inpatient or outpatient basis. CMS took a first crack at a better definition, but it was not well-received. For 2016, however, CMS came around on guidance that’s a little easier for hospitals to swallow:
- Maintains the benchmark established by the original Two Midnight rule, but permits greater flexibility for determining when an admission that does not meet the benchmark should nonetheless be payable under Part A on a case-by-case basis.
- Discusses a shift in enforcement of the Two Midnight Rule from Medicare Administrative Contractors (MACs) to Quality Improvement Organizations (QIOs), which would be in line with the multi-channel efforts aimed at promoting “quality care.”
- Provides more flexibility where patients may need less than two midnights of hospital care.
Making the most of flexibility
For those gray-area stays, inpatient admission may be payable under Medicare Part A on a case-by-case basis based on the judgment of the admitting physician. The documentation in the medical record must support that an inpatient admission is necessary, and is subject to medical review. For hospital stays that are expected to be two midnights or longer, CMS’s policy is unchanged; that is, if the admitting physician expects the patient to require hospital care that spans at least two midnights, the services are generally appropriate for Medicare Part A payment.
CMS emphasizes the role played by physicians in making this determination and its complexity: “The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting.”
Devising effective strategies
A recent white paper, which examined LOS for congestive heart failure and shock found that a 39% reduction in average LOS for these patients would save the case study hospital about $600,000 annually, while also presenting “associated revenue-enhancement opportunities accrued via improved bed availability, patient flow, and inpatient satisfaction.” And that’s for just one type of inpatient care, in one service line. In analyzing the ways in which the case study hospital could shorten LOS, the authors found 10 areas that hinder efficient discharge. Here is a selection, as well as some solutions:
- Poor documentation and communication. Using scribes is a solution that can ease reform within hospitals and among providers. With complete patient and care information recorded in real time, it is easier to share with other providers and facilities. Data can be extracted from these thorough records, to create trackable metrics.
- Inefficient in-house placement. Real-time dashboards implemented across the hospital can arm doctors, nurses, administrators, shift coordinators and nurse managers with the ability to optimize the flow of patients. For example, clinicians can visualize where bottlenecks are occurring, to decrease patient wait times.
- Delays in provision of care (nurse, physician and ancillary). Inpatient care necessitates the juggling of a lot of moving parts: pharmacy, diagnostics, physicians, nurses, allied health professionals and more are all working to efficiently move patients through without compromising quality of care. Certified medical scribes can be tasked with delivering messages between providers; can help the physician stay focused on the task at hand by recording notes from the tech, nurse, or another department; and can provide reminders to revisit patients or follow up on radiology or lab results.
- Variation in orders. Reduce variation in practices by developing both an order set and interdisciplinary pathway, and educating physicians and hospital staff in their use. Reducing unwarranted variation in medical practice increases value and improves quality of care in part because it allows for flexibility where patients or medical issues require specialized care.
- Insufficient patient education. Here, the documentation scribes create allows hospitals to quickly and thoroughly provide relevant information that will aid post-discharge care — and elucidate when and when to not return to the hospital. Creating a discharge educator role to orally reinforce these documented concepts with patients and caregivers can make written documentation more effective, while also helping to tackle social issues complicating care and discharge.
Seeing the overlap
At the same time, the aforementioned strategies are just what hospitals need to be doing to decrease preventable readmissions. The barriers to avoiding unnecessary readmissions include poor discharge planning and patient education, lack of communication (among providers and with patients/caregivers), not tracking metrics or service lines, and not having the flexibility to treat special cases appropriately. Focusing on LOS won’t hurt you with respect to CMS’s quality-of-care goals but, rather, better align you with them.