ABSTRACT:

Securing on-time discharges improves hospital throughput and optimizes patient flow and capacity. This is especially important during times of high census and ED boarding, which have significant patient experience and safety implications. The Hospital Medicine Service (HMS) cares for the largest volume of patients at UCSF Health, and often faces challenges in securing on-time discharges. Estimated discharge date accuracy for the service was as low as 62% in 2023 while length of stay averaged 8.1 days. Obstruction in on-time discharges often results from (1) variability in discharge planning practice patterns, (2) inadequate alignment among care team members on which patients are expected to discharge, (3) insufficient communication of discharge barriers, and (4) lack of coordination on which team member will complete discharge tasks. Since October 2023, the HMS has piloted the interprofessional “Accelerated Discharge Program,” (“ADP”), designed to enhance communication of anticipated discharge and streamline coordination on discharge tasks for patients most likely to discharge. The ADP team systemically collected data on common discharge barriers, developed expertise in addressing common discharge issues and discharge efficiencies, improved identification of patients likely to discharge and assisted with discharge tasks. Length of stay improved to 7.4 days in the intervention group. Through the Caring Wisely program, our interprofessional team seeks to develop a platform to communicate discharge barriers with other disciplines at the unit and the health system level through more Informatics and Apex build support. We ultimately aim to further increase the number of on-time discharges, improve estimated day of discharge (“EDD”) accuracy, reduce LOS, and support UCSF’s global capacity optimization efforts.

PROJECT LEAD(S):

• Monisha Bhatia, MD – Assistant Professor, Division of Hospital Medicine
• David Arboleda, MD – Assistant Professor, Division of Hospital Medicine
• Guinn Dunn, MD – Assistant Professor, Division of Hospital Medicine
• Prashant Patel, DO – Assistant Professor, Division of Hospital Medicine

EXECUTIVE SPONSOR(S):

• Bradley Monash, MD – Vice Chief of Clinical Affairs, Hospital Medicine

ABSTRACT:

Securing on-time discharges improves hospital throughput and optimizes patient flow and capacity. This is especially important during times of high census and ED boarding, which have significant patient experience and safety implications. The Hospital Medicine Service (HMS) cares for the largest volume of patients at UCSF Health, and often faces challenges in securing on-time discharges. Estimated discharge date accuracy for the service was as low as 62% in 2023 while length of stay averaged 8.1 days. Obstruction in on-time discharges often results from (1) variability in discharge planning practice patterns, (2) inadequate alignment among care team members on which patients are expected to discharge, (3) insufficient communication of discharge barriers, and (4) lack of coordination on which team member will complete discharge tasks. Since October 2023, the HMS has piloted the interprofessional “Accelerated Discharge Program,” (“ADP”), designed to enhance communication of anticipated discharge and streamline coordination on discharge tasks for patients most likely to discharge. The ADP team systemically collected data on common discharge barriers, developed expertise in addressing common discharge issues and discharge efficiencies, improved identification of patients likely to discharge and assisted with discharge tasks. Length of stay improved to 7.4 days in the intervention group. Through the Caring Wisely program, our interprofessional team seeks to develop a platform to communicate discharge barriers with other disciplines at the unit and the health system level through more Informatics and Apex build support. We ultimately aim to increase the number of on-time discharges, improve estimated day of discharge (“EDD”) accuracy, reduce LOS, and support UCSF’s global capacity optimization efforts.

TEAM:

• Brandon Scott, MD – Director of Value Improvement, Division of Hospital Medicine (DHM), Primary Project Mentor
• Rachel White, MHSA – Quality Improvement Program Manager, DHM, Program Manager
• Connie Li – Clinical Assistant, Goldman Medical Service (DHM), Team Member
• Priyanka Sapra – Clinical Assistant, Goldman Medical Service (DHM), Team Member
• Sarah Apgar, MD – Director, Goldman Medical Service (DHM), Core Advisor
• Ethel Wu, MD – Assistant Director, Goldman Medical Service (DHM), Core Advisor
• Lourdes Moldre, RN – Patient Care Director, Interdisciplinary Partner
• James Darby, RN – Parnassus Medicine Unit Director (14L/15L), Interdisciplinary Partner
• Ongoing discussions with Medicine Case Management Leadership and Patient Capacity Management Center leadership on partnership and integration
• Bradley Monash, MD – Vice Chief of Clinical Affairs, DHM, Executive Sponsor

PROBLEM:

UCSF’s Parnassus campus frequently experiences challenges with high capacity necessitating focused efforts to optimize on-time discharges within inpatient care teams.  The quality, safety, and financial consequences of a lower than predicted number of on-time discharges and include but are not limited to:

• Suboptimal patient satisfaction due to prolonged ED and PACU boarding
• Suboptimal care quality and risk of patient safety events, as the number of admitted patients “boarding” in the ED and post-procedural patients boarding in the post-anesthesia care unit (PACU) increases  
• Significant provider burnout and moral distress due to caring for patients in the “wrong care location”
• Limitations in outside hospital transfers, interservice transfers within UCSF, and direct admissions of patients needing UCSF tertiary/quaternary care
• Prolonged length of stay for admitted patients (e.g. discharge barriers not addressed earlier in the admission, thus adding a subsequent day to the patient’s hospitalization for care coordination)

For patients on the HMS, UCSF’s largest service by volume with over 7,000 Parnassus discharges in 2023, many delays in on-time discharge stem from deficiencies in the care team coordination and communication processes. For example:

• HMS multidisciplinary discharge rounds (MDR) are intended to raise awareness of anticipated discharge and discharge coordination needs but lack a structured communication method to alert other members of the interdisciplinary team and health system leaders of these needs. 
• The current workflow relies on accurate EDD to alert core services (Care Management (“CM”), Nursing, Pharmacy, Radiology, Rehab Services) when there are pending tasks for a patient expected to discharge. Inaccurate EDD misdirects resources and risks further delays to patients with accurate EDD. 
• Similarly, as the patient’s clinical condition and discharge needs evolve, we rely on CM to update EDD but there is variability in practice pattern on the frequency and detail of communication between clinicians and CM and there no structured communication of the changes that led to a change in the EDD.

TARGET:

• We seek to increase the number of on-time discharges of HMS patients by increasing their Estimated Discharge Date accuracy (“EDD accuracy”) from a baseline of 65% to 70% by improving communication of identified discharge barriers. Specific targets include:

• Develop a method for centralized, structured communication of identified discharge barriers to multidisciplinary team members at the unit and health system level 

• Leverage current Patient Capacity Management Center (“PCMC”) workflow (through increased EDD accuracy) and integrate with upcoming changes in throughput optimization efforts (via Deloitte redesign for Proactive, Timely Discharge Planning) to more proactively address discharge barriers on up to 2 days prior to EDD.

• Through these interventions we hope to achieve further reduction in Length of Stay (LOS): We anticipate expedited discharge barrier resolution resulting in earlier discharges that will lead in an average length of stay reduction of 0.3 days

GAPS

System issues and technological gaps include:

• Lack of centralized, structured communication of discharge barriers. Care team members use different EHR-based tools to track discharge barriers (such as Discharge Milestones, Discharge Comments, structured and unstructured text in clinical notes and patient list columns), leading to compartmentalization of information, inaccurate EDD, misdirection of resources.

Educational gaps include:

• Suboptimal multidisciplinary awareness of existing systems that can be proactively mobilized to support accelerated discharges.

INTERVENTION:

In October 2023 we initiated our Accelerated Discharge Program (ADP) pilot on the GMS which involved streamlining outreach to identify likely next day discharges, discharge barriers, and delegate task completion with our Clinical Assistant. ADP has developed standard work for interprofessional care team members to take on discharge tasks and, through a Hospital Medicine internal grant, plans to develop a discharge prediction model, structured tools for asynchronous communication and handoff between clinicians and interdisciplinary team members, and will pilot a delegated discharge model to offload discharges of clinically stable patients from the primary clinician. Moving forward, we seek increased support through Caring Wisely to develop a platform to communicate discharge barriers with other disciplines and the health system with goal of improving EDD accuracy and reduce LOS. Our proposal expands the ADP which has already demonstrated LOS reduction and cost savings and hope to yield sustained improvement. Specifically:

• Feasible EHR enhancements to existing discharge-focused EHR tools. We have laid the groundwork for cross-disciplinary communication using an order set and discharge checklist to identify discharge tasks and seek to work with Informatics and Apex build support to communicate this at the unit and health system level in a structured and centralized manner.
• Improve care management, clinician, nursing education about discharge-focused tools which can be leveraged to confirm and document barriers to discharge/discharge needs  

PROPOSED EHR MODIFICATIONS:

We will explore the following modifications which may impact EDD accuracy and LOS.

• Expansion / development of current “Discharge Delay” function to identify/flag discharge barriers which already integrates with PCMC workflow
• Continued modification / integration of the standard inpatient hospital medicine progress note (that now include discharge barriers) and connect this information to the central repository for visibility at the unit and health system level
• Explore similar modification / integration of current Care Management notes as above
• Reduce redundant areas for interdisciplinary discharge communication (e.g. Discharge Comments, Case Management Discharge Sticky Note, Patient List columns)

RETURN ON INVESTMENT:

We anticipate the ADP producing cost savings through reduction of length of stay in HMS patients. In the latest analyzed data from our current pilot, we found that from October 2023-June2024, average length of stay was 7.4 days. This was a 0.7 reduction from the average length of stay of all patients treated by the GMS hospitalists prior to the intervention July 2022-September2023 (8.1). We identify a 0.3 day reduction in LOS as a conservative estimate of length of stay reduction by improving interdisciplinary communication and further improving EDD accuracy with future support from Caring Wisely. We identify a 0.7 day reduction in LOS as an optimistic estimate given the data collected.

Collectively, we anticipate direct cost savings to the health system attributed from reduction in HMS length of stay leading to decreased direct variable costs from bed days saved over one year’s time to range from $1,315,242 (0.3 reduction in length of stay for GMS service) to $3,068,898 (0.7 reduction in length of stay for GMS service) as outlined attached document. True financial impact expected to exceed these figures as these estimates do not consider savings from additional cost of care delivery beyond direct variable cost of a bed nor increase in revenue/contribution margin arising from backfill as UCSF Health Parnassus Heights’ hospital capacity increases as a direct result from the accelerated discharge program.

SUSTAINABILITY:

• We aim to intentionally implement interventions that integrate into existing resources/processes and care team members (e.g. Case Management MDR and tee time, Flow Control Team rounding, GMS clinical assistant, EDD and Discharge Report APeX tools, CARTBoard and enterprise throughput dashboards) to ensure long-term sustainability. The Caring Wisely funding year will be utilized to establish successful centralized structure communication that can be feasibly adopted by current process owners for hospital discharges and throughput and once adopted will not require ongoing support for maintenance. We anticipate success in this project to lead to adoption of ADP core features and structured communication by other service lines.
• We believe our interventions will be able to achieve sustained cost-savings without the need to hire additional care team members. Our goal is to better leverage, connect, and streamline our existing processes to produce faster, safer, and higher quality discharges for patients and care providers alike through communication practices, establishing norms, and APeX enhancements as described above.

BUDGET:

• $30,000 – effort for project lead(s)
• $20,000 – reserved for as-needed clinical informatics support (e.g. data analysis, EHR modifications