Creative solutions to difficult discharges

Denver Health Medical Center's complex discharge committee helps find creative dispositions for patients who are medically ready for discharge but, for many reasons, unable to leave the hospital.


Where: Denver Health Medical Center, a 477-bed acute care hospital in Colorado.

The issue: How to deal with patients whose outside circumstances make discharge more complicated than usual.

Background

As a public safety-net hospital, Denver Health treats a large number of uninsured patients. “Forty-six percent of our patients have no payer source when they get admitted,” said Philip Mehler, FACP, chief medical officer of the hospital. “They are often therefore unfortunately enriched with complex psychosocial issues, and may have issues with substance abuse, may have psych issues, may have behavioral issues, or they may not be U.S. citizens.”

The patients' financial and psychosocial issues come to the forefront when they are medically ready for discharge. They may no longer need hospital care, but if there is no payment source for them to receive a lower level of care, they often remain in the hospital, even though their beds are needed.

Dr. Mehler came up with a solution: the complex discharge committee, a group charged with developing creative dispositions for these patients.

How it works

The committee has several members who are knowledgeable about the patients' specific situations, including hospitalists, utilization management nurses and social workers. “Then on the other side of the table, you want the people who can maybe push the right button to creatively give you a solution, so we have the CFO of the hospital there, the COO of the hospital there, myself the CMO, the head of the legal department, and a psychiatrist,” said Dr. Mehler.

The committee meets once a week to review a list, compiled by the patient care side, of all the patients who are medically ready for discharge but unable to leave. They have to have been in the hospital for at least 10 days. In a typical week, 20 to 30 make the list. The patients are categorized by the source of their disposition problem—no payer, psychiatric problems, immigration issues, or need of a guardianship determination.

“This list we go over in detail trying to look for creative solutions to move these people to the next level of care that they need,” said Dr. Mehler. For example, the hospital had a patient who sustained a serious injury in an accident and required nursing home care. He was not eligible for Medicare, so no nursing home would take him, and his family lived in a distant country.

“We could leave him here for the next four years until he dies from natural causes, or we said to the CFO of the hospital, ‘We need to send a doctor who speaks the patient's language with this guy on an airplane to get him home,’” explained Dr. Mehler.

Other solutions have involved contacting the consulate of a foreign patient's home country, assisting families with home health care payments, and negotiating with nursing homes.

Results

The effects of the complex discharge committee have not been measured in isolation, but the hospital has seen improvements in related indicators since the program's inception. “Due to a lot of things, this being a part of it, our length of stay has fallen from about 4.7 to about 4.1 days. That doesn't sound like much, but when you take the number of admissions that we have a year, which is close to 30,000 patients, and you decrease their length of stay by a tenth of a day, you can see that that adds up to a lot of patient days,” Dr. Mehler said.

How patients benefit

The hospital's bottom line is not the only beneficiary, he noted. “Hospitals are not safe places to be. We all know the problems that happen in hospitals and the longer you're in a hospital, the more chance that something bad is going to happen to you.”

Challenges

Although the process works for many patients, some discharge issues are so complex that even the committee can't solve them. About half of the patients discussed in a weekly meeting are “repeat offenders” whose cases have been previously reviewed but not resolved, according to Dr. Mehler.

Lessons learned

The committee hopes its work can be a model for other safety-net hospitals. The process starts with gathering accurate, well-categorized data about the patients. “Then you've got to have a dedicated group that gets together in a very systematic fashion to deal with it,” Dr. Mehler said. “You need a group around the table who has the power to make decisions and who has the insight into the organization to weigh the pros and cons and make a reasonable decision.”