A New Look at Hospital Length of Stay: Substantial Benefits Emerge through Focus on Care Transitions
Brian Pisarsky, Tina Pike
Brian Pisarsky, Tina Pike
Proactive hospital leaders are hard at work redesigning and implementing processes and systems to ensure the right care is delivered, in the right setting, at the right time, with the right workforce—every time, for every patient.
A leadership focus on LOS-related issues arising during care transitions can shed light on improvement opportunities for enhanced patient experience, satisfaction, and safety; greater efficiency; and real savings from both reduced excess patient days in the acute care setting and better throughput across the continuum of care.
The article begins with the description of a leading assessment process that identifies improvement opportunities at a high level. This is followed by practical recommendations to achieve LOS-related operating and financial benefits as the patient enters, receives, and exits acute care, and as foundational work occurs across these interconnected stages. Recommendations stem from initiatives that currently are taking place in many hospitals and health systems nationwide.
Assessment of an organization’s care management model provides the starting point for identification of LOS improvement opportunities—particularly, how people, processes, and technology currently are involved in every step of a patient’s care coordination throughout the care continuum.
These elements should work synergistically to coordinate the patient care journey effectively from portal of entry through discharge to the appropriate level of care. A high-level comparison of a hospital’s current performance with leading practices in hospitals around the country enables identification of promising improvement opportunities in each domain.
Figure 1 illustrates people, process, and technology improvement opportunities compared to leading practice. Items in red indicate the components with the greatest opportunity to achieve an efficient care management process—i.e., those items furthest from leading practice.
The patient’s overall acute care experience includes transitions at the following points: entry into the system of care through one of the portals of entry; initiation of, and changes within, acute care provision; and discharge to home with appropriate services or to other post-acute settings. An organization’s denial prevention and management function works across these three phases to ensure continuity of care and payment for that care (Figure 2).
Recommendations to achieve LOS-related, denial prevention, and operating and financial benefits at each phase follow.
Expected results, all of which reduce LOS and prevent denials, include seamless patient admission and accurate patient status assignment; appropriate management of patients from all portals of entry, whether the ED, surgery department, direct admits from a physician’s office, transfers from other facilities, or others; and system-wide understanding of pre-certification requirements and the ramifications of noncompliance. Additionally, consistent identification and implementation of needed changes, denial prevention, and the early identification and resolution of any payer eligibility issues and gaps in coverage set the stage for the next phase of the redesign process.
Expected results also include improved safety and patient satisfaction, a comprehensive approach to discharge planning by all members of the care team, and better alignment of the organization’s average LOS to the Medicare geometric mean LOS (GMLOS). The proactive identification and resolution of throughput barriers prior to expected or anticipated date of discharge facilitate progress toward best-practice performance in all care management processes.
Length-of-stay reductions from improvement in care transitions produce impressive results.
Figure 4 provides a look at the benefits an example organization may be able to achieve with low (25%), medium (40%), or high (55%) targets for percent improvement. The “excess day opportunity” is calculated by subtracting the number of inpatient days an organization expected in a fiscal year based on the Medicare GMLOS (in this case 80,000 expected days) from the observed or actual number of inpatient days (126,000 days) in that same fiscal year. Thus the example organization has an “excess day opportunity” of 46,000 inpatient days (126,000 - 80,000 = 46,000 days).
The numbers in Figure 4 represent significant cost-reduction and revenue-improvement progress, even at the lower end of improvement achievement. In our experience, organizations with leading care management practices in place typically can achieve 35-40 percent reduction of excess days through targeted and facility-specific interventions.
A collaborative approach and best-practice processes ensure that the patient gets the right care, in the right setting, at the right time—every time. Effective care transitions not only improve patient safety and experience, but reduce length of stay with the benefits quantified here.
As Vermont continues to move toward a global healthcare payment model, hospitals and health systems in the state are under pressure to advance their ability to operate in a value-based care environment designed to minimize cost and optimize quality.
Understanding how an organization is performing across a broad set of initiatives—for strategic growth and tactical improvement—is a formidable task.