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
• Michelle Mourad, MD - Vice Chair of the Department of 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, but 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. Discharge delay can result from (1) variability in discharge planning practice patterns among hospitalists, (2) inadequate alignment among interprofessional 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 following day. The ADP team systemically collected data on common discharge barriers, developed expertise in addressing common discharge barriers and inefficiencies, improved identification of patients likely to discharge and assisted with completing discharge tasks. Length of stay improved from 8.1 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 Informatics and APeX build support. We ultimately aim to increase the number of on-time discharges, reduce length of stay, 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
• Sarah Apgar, MD – Director, Goldman Medical Service (DHM), Core Advisor
• Ethel Wu, MD – Assistant Director, Goldman Medical Service (DHM), Core Advisor
• Ongoing discussions with Medicine Case Management Leadership, Nursing Leadership and Patient Capacity Management Center Leadership on partnership and integration
• Bradley Monash, MD – Vice Chief of Clinical Affairs, DHM, Executive Sponsor

PROBLEM:

The UCSF 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 include but are not limited to:

• Suboptimal patient satisfaction due to prolonged ED and post-anesthesia care unit (PACU) boarding
• Suboptimal care quality and risk of patient safety events, as the number of admitted patients “boarding” in the ED 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 who require UCSF quaternary care
• Prolonged length of stay for admitted patients (e.g. discharge barriers not addressed earlier in the admission, adding subsequent day(s) to the patient’s hospitalization for ongoing care coordination)

For patients on the HMS, UCSF’s largest service by volume with over 7,000 Parnassus Campus discharges in 2023, many delays in on-time discharges 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 tasks but lack a structured communication method to alert other members of the interdisciplinary team and health system leaders of these tasks.
• The current workflow relies on accurate EDD to alert and prioritize core services (Case Management (“CM”), Medical Social Work, Nursing, Pharmacy, Radiology, Rehabilitation Services) when there are pending tasks for a patient expected to discharge. Inaccurate EDD misdirects resources and risks further delays to other patients more likely to discharge.
• 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, without structured communication or feedback pertaining to changes that extended the EDD.

TARGET:

• We seek to increase the number of on-time discharges of HMS patients by improving communication of identified discharge barriers. Specific targets include:
  • Develop a method for centralized, structured communication of identified discharge barriers which is visible to multidisciplinary team members at the unit and health system level and integrates with frontline multidisciplinary team workflows
  • Leverage current Patient Capacity Management Center (“PCMC”) workflows 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 that can be easily updated directly by the physician caring for and ultimately discharging the patient. Care team members use different EHR-based tools to track discharge barriers (such as Discharge Milestones, Discharge Comments, the MDR Discharge Planning Tool, and structured and unstructured text in clinical notes and patient list columns), leading to compartmentalization and redundancy of information in discordant areas in the electronic health record (EHR), inaccurate EDD, and misdirection of resources.
• Inconsistent documentation of the discharge plan in primary team clinician notes or in other locations like sticky notes, discharge navigators. There is variability in documentation of the discharge plan, which we are attempting to address with standardized note templates. However, even when these fields are completed, the information is not readily available to other members of the interprofessional team and health system leadership who are attempting to expedite discharges.
• No shared understanding of the global discharge plan between disciplines despite implementation of the discharge milestones tools. Each member of the interprofessional team has access to important information that may alter the discharge plan but this information is not quickly accessible to the care team and currently requires duplication of work and additional person-to-person communication, increasing the burden of communication.

 Educational gaps include:

• Suboptimal interprofessional 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 HMS’s direct care teams, which involved streamlining outreach to identify likely next day discharges, discharge barriers, and delegate specific tasks to our Clinical Assistant. ADP has developed standard work for interprofessional team members to take on discharge tasks and, through a Division of Hospital Medicine internal grant, plans to develop a novel discharge prediction model, structured tools for asynchronous communication and handoff between clinicians and interprofessional team members, and will pilot a delegated discharge model to offload the discharge 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 interprofessional team members and the health system with the goal of reducing length of stay by a further 0.3 days. Our proposal expands the ADP which has already demonstrated LOS reduction and cost savings, with the hope to yield sustained improvement. Specifically:

• Feasible EHR enhancements to existing discharge-focused EHR tools. We have laid the groundwork for interprofessional 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. We recognize this will need to synergize with the existing Case Management MDR tool launched 3/12/2025, but hope to use human-centered design principles to optimize how primary hospitalists making the decision to discharge can best interface with the tool in real time, as discharge plans vary throughout the day.
• Improve case management, clinician, and nursing education about discharge-focused tools which can be leveraged in real-time to confirm, document, and overcome discharge barriers.  
• Continue to develop, expand and integrate current ADP deliverables (discharge prediction model, ADP order set, discharge checklist) into a centralized, structured area in the EHR which can be accessed at the unit and health system level and be used by PCMC or individual nursing units to direct resources to ensure timely mobilization after the patient is determined to be medically ready for discharge and discharge orders are placed.

PROPOSED EHR MODIFICATIONS:

We will explore the following modifications which may reduce LOS.

• Expansion and development of current “Discharge Delay” function to identify/flag discharge barriers which already integrates with PCMC workflow
• Continued modification and integration of the standardized inpatient hospital medicine progress note (which now includes listed discharge barriers) and connect this information to the developed centralized EHR enhancements for visibility at the unit and health system level, to escalate and execute discharge tasks.
• Explore similar modification and integration of current Care Management notes as above.
• Reduce redundant areas of interprofessional discharge communication (e.g. Discharge Comments, Case Management Discharge Sticky Note, Patient List columns), instead focusing on the centralized and visible EHR enhancements. 

RETURN ON INVESTMENT:

We anticipate the ADP to produce 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-June 2024, the 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 HMS direct care hospitalists prior to the intervention July 2022-September2023 (8.1 days). We identify a 0.3 day reduction in LOS as a conservative estimate of length of stay reduction by improving interprofessional communication with future support from Caring Wisely. This target is scalable and realistic, even for services with shorter baseline LOS. 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 to reduction in HMS length of stay. This will lead 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 in the attached document. The true financial impact is expected to exceed these figures, as  we expect additional savings from cost of care delivery beyond direct variable bed-day cost   and increase in revenue /contribution margin from backfill of the UCSF Health Parnassus. We have aimed for a smaller impact in part because of anticipated increases in complex patients admitted to Parnassus campus as a result of health system efforts to transfer lower acuity patients to other sites (St. Mary’s Hospital, Mt. Zion Hospital), changes in scheduling practices within HMS, and other system-wide changes which may make it challenging to analyze the individual impact of our project. We believe our project is even more vital in this environment, as the forward flow of patients from all sites will remain a system priority that will be even more challenging for individual clinicians to navigate without care coordination support. To address the challenge of controlling for other concurrent health system efforts, we will continuously adapt our approach and iterate our processes with the guidance of our interprofessional stakeholders, advisors and executive sponsors.

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 (afternoon discharge planning), Flow Control Team, HMS direct care 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 a successful centralized and structured communication enhancement within APeX that can be feasibly adopted by current process owners for hospital discharges and throughput. Once adopted, our intervention will not require ongoing support for maintenance. We anticipate success in this project to lead to adoption of ADP core features and structured communication to scale to other service lines, including our partner sites (St. Mary’s Hospital, Mt. Zion Hospital) which will allow information sharing to enhance discharge workflows across the entire health system.
• We believe our interventions will 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 improving communication practices, establishing norms, and enhancing APeX as described above.

BUDGET:

• $35,000 – effort for project lead(s)
• $15,000 – reserved for as-needed clinical informatics support (e.g. data analysis, EHR modifications)