Published in the November 2005 issue of Today’s Hospitalist
For the past year and a half, many patients leaving the wards of Salem Hospital have seen a new type of health care provider at discharge time.
Instead of seeing one of the five hospitalists at the hospital in Salem, Mass., these patients have seen a transitionalist. At Salem, that person is a nurse practitioner who has taken on many of the discharge duties previously handled by physicians. She talks to patients and their families, writes prescriptions and issues the final discharge orders. She has taken on so much of the discharge process, in fact, that patients often don’t see a physician on their last day or two in the hospital.
Salem’s approach to streamlining its discharges may be unusual, in part because it has put so much of the process in the hands of a nonphysician. But as hospitalist services search for ways to streamline their discharge process, more are hiring nurses who focus exclusively on patient discharges.
The goal is to make better use of precious physician time and devote additional resources to what some hospitalists describe as “transition points” “admission and discharge “where problems can develop. Here’s a look at how three programs are using nurses to ramp up and streamline their discharge process.
Giving case management a jump-start
Hospitalist groups that bring nurses on board to coordinate discharges are often looking for staff to serve as a liaison between their hospital’s case managers and the hospitalists, not to replace case managers.
Steve Nahm, a consultant with The Camden Group in El Segundo, Calif., says that these programs often have their nurses attend morning hospitalist handoff sessions, a process that leads to discussions about who was admitted the night before, who can be discharged today, and who can be discharged in the next day or so. The hospitalist nurse then reviews that information with the hospital’s case managers, who finalize discharge arrangements. This arrangement is especially helpful when case managers are assigned by units, rather than by patient or physician.
At Bryan LGH Medical Center West in Lincoln, Neb., Sara Morris, RN, fills that type of role. Ms. Morris, a nurse coordinator for Inpatient Physician Associates, a group that works at the hospital, spends most of her days preparing patients for discharge.
As soon as patients arrive at the hospital, Ms. Morris immediately assesses their needs and tries to anticipate the services they’ll require when they return home. She’ll then talk to hospital social workers and case managers to begin making arrangements for these patients’ discharge.
Ms. Morris also spends a good part of her day communicating with family members and answering questions.
“We might talk with family members who may not understand why we’re sending the patient to a skilled nursing facility instead of home,” she says. “We handle patient education, so if the patient has a PE, we’ll discuss INRs, coumadin and other information with patients and the family. When there are questions for the physician, it’s minimal.”
Saving physician time
Once the patient is ready to be discharged, Ms. Morris writes the discharge orders and puts the finishing touches on the medication list. When physicians arrive for the discharge, all they have to do is review the discharge order, dictate the notes and call the primary care physician.
“It saves them a lot of time when it comes to doing the discharges,” Ms. Morris says. “We’re able to meet with the family members and answer a lot of the simple questions, so physicians don’t have to spend an hour meeting with them.”
Michele Steckelberg, MD, a hospitalist with the group, agrees that having a nurse tackle many of the details of discharge planning streamlines the process. “The nurses do a great job of getting in and talking with the patient, sometimes before we even get there,” she explains. “They’ll explain that we’re thinking about sending the patient home today and ask what kinds of questions they have for the doctor.”
The hospitalist nurse also simplifies communications between the hospitalists and unit nurses. “If it’s an easy sort of thing, like a matter of pulling a patient’s foley catheter out,” Dr. Steckelberg says, “the unit nurse will go through the hospitalist nurse, which saves us the hassle of a phone call. If it’s a more complicated patient issue, they’ll go through us directly, unless the nurse happens to be around, then she’ll track one of us down.”
Increased productivity and satisfaction
While there are no hard figures on exactly how much a hospitalist nurse coordinating discharges can improve the efficiency of a hospitalist group, practice consultants like Martin Buser, MPH, estimate that the strategy is usually so successful that it boosts productivity by 20 percent.
Mr. Buser, a founding partner of Hospitalist Management Resources LLC, a hospitalist consulting firm with offices in San Diego and Colorado Springs, Colo., explains that the strategy also brings other benefits, such as increased physician satisfaction. He notes that hospitalists often report that coordinating discharges is one of the least favorite parts of their jobs.
“When we survey hospitalists,” Mr. Buser says, “we ask them what they like best about their job and what they hate most about their job. They typically say they hate doing discharge summaries because of all the medications that have to be written down. One hospitalist told me that if the CEO of a hospital had to do discharge summaries for three days, the whole process would be automated to make it more efficient.”
At many hospitals, however, the medication reconciliation process remains far from automated, which makes it one part of discharge that’s ripe for improvement. Our Lady of the Lake Regional Medical Center in Baton Rouge, La., uses its nurse coordinators to build a better medication list.
Staying on the same page
As patients are admitted to Our Lady of the Lake’s 11- physician hospitalist program, one of the hospitalist nurses begins planning for discharge. One of the immediate goals is to create an up-do-date medication list, which helps facilitate discharge.
“As discharge draws near,” explains Richard M. Slataper, MD, director of the hospitalist service, “we have a very easy way to add, modify or discontinue medications on the sheet. That worksheet becomes a focal point for coordination between our nurses and physicians. We are also currently participating in a hospital information services committee to further automate the process for the entire medical staff.”
At admission, nurses verify the accuracy of patient information in the hospital’s records, which can be inaccurate. Dr. Slataper adds that nipping those discrepancies in the bud similarly helps makes patient discharges go more smoothly a few days later.
He also notes that hospitalists aren’t the only ones who benefit from the presence of hospitalist nurses in the discharge process. The strategy also makes life inside the hospital more sane for the unit nurses.
“With national nursing turnover at 21 percent and rising, we are looking for opportunities to lighten the unit nurse workload,” Dr. Slataper explains. “Sitting down to do a discharge on a complicated medical patient is a time-intensive endeavor. Taking a 20 or 25 minute block of time to do a proper discharge becomes a somewhat daunting item on the to-do list when there are competing tasks.”
The role of an NP
While a worksheet that can be accessed by both nurses and physicians is one way to keep nurse practitioners and hospitalists on the same page, hospitalists at Salem Hospital use another fairly common approach: daily case management rounds. These meetings give the physicians and the nurse practitioner a chance to review patients who are appropriate for discharge in the next day or two.
While there are some similarities between the way Salem and other hospitalist programs approach discharge planning, the hospital’s NP is fairly independent in coordinating discharges. She does not need a physician to sign or review her discharge instructions, which often means patients don’t see a physician on the day of discharge.
How do patients feel about not seeing a physician on their final day in the hospital? Justin Byrne, MD, director of the hospitalist program at Salem Hospital, says that it’s rarely an issue. If a patient is likely to be ready for discharge the next day, the hospitalists tell the patient that a nurse practitioner will take over.
“I’ll usually tell them that tomorrow they’ll probably see our nurse practitioner who will help them coordinate everything on your discharge if everything goes well,” Dr. Byrne says. Besides, he adds, because the group’s NP is generally able to spend more time with patients than physicians, patients often like seeing her.
The NP, who previously worked as an ICU nurse, also directly bills payers for her services. While she collects only 85 percent of what physicians in the group can bill for, Dr. Byrne points out that because she is paid significantly less than physicians, the group earns a profit on her services, something that is not usually true of the group’s physicians.
After the discharge
Groups getting nurses involved in discharge are finding opportunities for improvement even after the patient has left the hospital.
At Our Lady of the Lake, nurses place a follow- up phone call to patients a day or two after discharge. Dr. Slataper says that having the nurse who created the discharge plan make the follow-up call presents several advantages. Not only is continuity of care preserved, he says, but the nurses constantly hone their discharge skills. “They get to see how well their preparation played out,” Dr. Slataper explains, “and they can adjust their approach.”
During the follow-up calls, nurses ask whether the patient kept the follow-up appointment, whether they filled their prescriptions, and whether an outside agency (home health, hospice, or physical therapy) showed up. They can track which agencies do a good job and which ones may need a second look.
The nurses also ask if any new health problems have come up. That question alone, Dr. Slataper says, results in nurses making a second phone call to about 25 percent of patients who have been discharged.
While Dr. Slataper’s program has had hospitalist nurses for years, only in the last year has it really focused nurses on admissions and discharges.
He says that admission and discharge are two critical transition points that need to be better addressed in hospital medicine. “We recognize that the transition point of either accessing health care or exiting health care are probably the highest-risk points for patients,” he says.
While doctors will always remain an important part of the discharge process, Dr. Slataper says his program’s nurses have developed an expertise in identifying the difficult issues that are part of discharge.
“Everyone is different,” he explains, “which is why we so value the hospital medicine service nurses. They’re really focused on this process and complete the loop in terms of the follow-up phone call. The goal is to set up a process that allows us to continually get better and learn as time goes by.”
Edward Doyle is Editor of Today’s Hositalist.
Making the case for hiring a nurse to help with discharges
While hiring a hospitalist nurse to oversee patient discharges can help improve productivity, physician satisfaction and possibly readmission rates, hospitalists worry “and sometimes rightly so, experts say “that they face a tough sell with hospital administrators.
“Hospitalists have been fairly timid about even asking for a discharge clerk, thinking it adds more costs to the program when they’re already asking for assistance,” explains Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC, a hospitalist consulting firm with offices in San Diego and Colorado Springs, Colo.
Mr. Buser says that hospital administrators often cringe at the idea of giving a hospitalist program already running in the red even more money to hire additional staff. “They think this is another $80,000 they have to pay for a nurse and benefits,” Mr. Buser explains.
The hide-and-seek model
Mr. Buser says that in his experience, however, not having a hospitalist nurse coordinate the discharge process can lead to problems. Consider the typical scenario, in which hospitals assign a case manager to every floor, with a case manager on the medical ward, one on the surgical ward, and so on.
As hospitalists move into areas like co-managing surgical patients, their patients tend to be spread out all over the hospital. As hospitalists work with more and more departments throughout the hospital, they begin wasting precious time trying to find the case managers on the different floors where they’re working.
It’s one reason why Mr. Buser claims that giving hospitalists a dedicated discharge planner can help boost productivity by 20 percent. “Instead of the typical ‘hide-and-seek’ model of discharge planning,” he explains, “you have someone connected at the hip. Having that person right there in daily rounds raises productivity another 20 percent, and it ultimately helps reduce length of stay.”
To make it easier for hospitalists to talk to case managers, Mr. Buser adds, hospitals sometimes hold morning case management rounds to bring all the discharge planners and day hospitalists together. Mr. Buser says that after about eight months, however, the strategy often fizzles.
“They come back and say this is really unproductive, we’ve got all these case managers tied up waiting to meet with doctors when there are other patients they should be seeing,” he explains. “There’s nothing better than having the one key case manager right there.”
Picking the right title
Even if you’re sure that a hospitalist nurse can help you streamline discharges, how can you convince hospital administrators?
Steve Nahm, a consultant with The Camden Group in El Segundo, Calif., says that when asking for a hospitalist nurse, be prepared to explain the value it will bring in terms of the admission and discharge processes efficiencies, as well as the nurse’s role in reaching program goals like patient satisfaction, medical record documentation and post-discharge communications with patients and primary care physicians.
If you say that your service needs its own nurse, he explains, administrators may not understand how the role of the hospitalist nurse differs from floor or case management nurses. They may also worry that if they give the hospitalist program its own nurse, other services in the hospital will demand their own nurses as well.
That’s why Mr. Nahm advises hospitalists to ask for a nurse who serves as a hospitalist program coordinator with multiple responsibilities, not an RN to replace the hospital’s unit nurses or case managers. By emphasizing the nurse’s focus on overall program goals and facilitating post-discharge communications, Mr. Nahm says, “You’ll avoid resistance from not only hospital administrators, but from case managers who want, and should, maintain a firm grip over case management activities in the hospital.”
And if you don’t succeed at first, try again. While Mr. Nahm ideally tries to make sure that the hospitalist programs he sets up have a nurse coordinator from day one, has also represented existing programs trying to add one to already established programs.
“Once a hospitalist program is in place,” he says, “it’s easier to get additional resources. The value of the program is pretty well-accepted by that point and the medical staff is supportive. It isn’t under the magnifying glass, and the benefits from ensuring a successful program are understood.”
The value of face time
Mr. Buser offers another strategy hospitalist programs can use to build on their success: Meet regularly with hospital administrators to talk about your successes and challenges to further growth.
“If you’re starting to show improvement in length of stay and changing behaviors and practice patterns in the hospital,” he explains, “and the administrator is getting good feedback from the nurses and medical staff, meeting on a regular basis with the administration gives you a chance to talk about problems with case management. That sets the groundwork.”
“If you can’t make the case on day one,” Mr. Buser adds, “hang in there and keep the regular meetings with the administrator or his designee to make this change. We’ve seen this work effectively, where over time the administrator says, ‘You’re right.’ ”