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Optimizing Coordination Among Mid-Revenue Cycle Stakeholders
Timothy Brundage, MD, CCDS
Medical Director / Chief Executive Officer - Brundage Group

Across many hospital systems, the demand for patient beds outweighs the supply. This can lead to a plethora of problems, including surgery cancellations, declining patient and staff satisfaction, and increased length of stay for patients in every setting, e.g., inpatient, emergency department, etc. Further, when capacity is a problem, hospital leadership spends unnecessary time addressing capacity management issues—valuable time that cannot be regained.

Hospital leadership would agree there is a need to develop a strategic process to manage bed capacity. Ideally, a plan would be developed through collaboration of hospital leadership and hospital-wide staff, with solutions that focus on maintaining or improving quality and outcomes. From a staffing perspective, when staff efficiency increases, employees are less burdened with managing capacity issues and more focused on patient care. For patients, having a bed available in the right setting makes them feel valued and cared for, resulting in a positive effect on patient satisfaction and outcomes.

Emergency Department (ED) crowding is not a problem that exclusively impacts the ED, but rather one that impacts all patient care areas and requires hospital-wide solutions. Long wait times can lead to potential safety events and dissatisfaction with overall care. Addressing ED crowding should be at the forefront of organizational improvement efforts, as it is costly and compromises care quality and public perception and trust.

The Pilot
Brundage Group embarked on an ambitious pilot project to solve patient throughput issues by targeting patients with hospitalization orders who remained in the ED awaiting bed assignment. Integral to the project was a dedicated physician advisor in the ED to help optimize workflows, admission, and discharge processes. The goals of the pilot were to confirm accurate level of care orders at the time of admission; reduce avoidable admissions; and improve communication between the ED physician, admitting hospitalist, and ED case manager.

The ED project was a collaboration between Brundage Group and a Level 1 Trauma Center that is one of the largest hospitals in Florida. A hospital representative will co-present the session, Optimizing Coordination Among Mid-Revenue Cycle Stakeholders, along with physician advisor, Dr. Timothy Brundage, during ABQAURP’s Annual Health Care Quality & Patient Safety Conference.

The Team
The project team included a physician advisor as the dedicated resource for the pilot; a utilization management nurse to create a UM presence that did not previously exist in the process; an ED care coordinator/case manager (CM), who refocused efforts to prioritize ED discharge planning; and an ED social worker (SW), who remained focused on serving ED patients.

New Concepts
The team developed a process to target "boarder" patients - a patient who requires care beyond ED services but remains in the ED because there is no hospital bed available. As part of the pilot, the project team would meet in the ED at multiple standing times throughout the day to review all boarder patients.

To help encourage efficient patient throughput, the team leveraged case management services. While CM is required for inpatient, the team realized the CM role could also be applied in the ED to help support the patient discharge process as appropriate while enabling the ED to treat a greater capacity of patients. During the frequent meetups, the team leveraged these dedicated ED CM/SW teams to identify patients for whom referrals could be obtained for additional services allowing discharge directly from the ED.

Level of care determinations had a two-prong approach. Led by the physician advisor, the boarder round team helped to ensure appropriate level of care status and would contact the attending physician if a status order needed correction. Additionally, UM nurses were tasked with reviewing ED cases outside of boarder rounds, referring identified cases directly to the dedicated ED physician advisor. A key element was the physical placement of the UM nurse within the ED to directly communicate with ED physicians as quickly as possible to support accurate status determination and maximize real-time communication.

The results of the pilot program showed significant reduction in avoidable admissions, validated patient status determinations, and a change in the ED physician culture, becoming more confident that discharge planning could be safe and efficient with appropriate support from the CM/SW role.

The outcomes underscored the need for a dedicated ED physician advisor to add credibility to the project and to optimize the discharge process. Further, reviewing a case for appropriate level of care early in the ED stay improved the accuracy of level of care determinations and ultimately improved hospital capacity management. The pilot project also spurred a change in ED physician culture that extended to the general medical staff through education and physician advisor engagement.

Learn about the specific outcomes of the emergency department pilot program during Dr. Timothy Brundage’s session at the ABQAURP Annual HCQ&PS Conference, “Optimizing Coordination Among Mid-Revenue Cycle Stakeholders,” on Friday, October 7, 2022, at 4:30 p.m. For more information and to register, visit www.abqaurp.org/AnnualConference.