If I’ve heard it once, I’ve heard it 100 times (a day), “How can we reduce the length of stay for our patients?” This question is increasingly becoming the Achilles’ Heel of a case manager’s discharge plan. That, in combination with the pressures to reduce potentially avoidable readmissions, keeps case managers up at night. I believe the length of stay in a hospital is heavily correlated to a readmission. A premature discharge is just as risky as an admission that drags on unnecessarily, and I’ve always challenged hospital administrators on their constant pressure to discharge my patients as quickly as possible. Oftentimes, this strategy is counterproductive and results in patients being pushed out of the hospital too soon, causing them to end up right back in the emergency room.
Nationally, according to the Centers for Medicare and Medicaid Services (CMS), the average length of a hospital stay decreased by a significant 44 percent from nine days in 1990 to five days in 2014. Now don’t misunderstand, we all agree the preference for patients and their families is to return to life outside the hospital as soon as possible. The longer the patient remains in the hospital, the greater the likelihood of an adverse event – hospital acquired infections, medication errors, unnecessary and costly tests and procedures, falls, etc. That being said, we need to focus less on reducing length of stay and more on optimizing the treatment plans while the patient is hospitalized.
Granted, it’s hard to dispute the high costs of an extra day or two in the hospital. In 2014, the average cost per inpatient day was $2,346 at non-profit hospitals and $1,798 at for-profit hospitals. However, the costs of a readmission are even higher. This is true, not only in terms of dollars, but from the patient’s perspective as well. A whole new set of tests are run, new medications with new side effects are prescribed, a more complicated discharge planning process occurs, and the emotional roller coaster associated with a readmission is stressful for everyone.
A recent study out of New York examined 12,341 admissions from 79 physicians to determine how a shorter length of stay impacts patient outcomes. The results were compelling and found that patient admissions from “short length of stay physicians” were associated with a significantly higher “30-day mortality”. Clearly, a premature discharge from the hospital can be dangerous to your health.
So, how do we optimize length of stay to achieve the best outcomes? Once again, we look to the case manager to coordinate the plan. The case manager is the quarterback. She must remain in constant communication with the patient’s entire care team from the minute the patient is admitted. She must listen carefully to the physicians’ proposed treatment plans, including the expected timing of the discharge and alert the team to potential barriers, especially the often overlooked impact of social determinants that can negatively influence the patient’s transition to the next level of care. Oftentimes, the case manager concludes that one or two additional days in the hospital will greatly lessen the chance of a readmission.
Of critical importance to the case manager’s successful care plan is access to the highest quality post-acute services available to the patient based on his personal situation: insurance coverage, financial means, family support, living arrangements, ability to resume his routine activities of daily living, etc. Often, the patient can safely return home if he has the support he needs.
One of my many memorable patients, Frieda, was a 90-year-old, highly independent woman who had a history of Congestive Heart Failure (CHF). She was admitted to the hospital with CHF exacerbation. We implanted a pacemaker, diuresed her through a medication adjustment, increased her oxygen requirements and educated her on her diet and salt intake. She was ready to go home. The medical team and her family, however, didn’t agree with Frieda’s plan. I remember her taking my hands into her own and pleading with me to help her return home. I convinced the team to postpone her discharge for a day and a half (despite exceeding the strict length of stay guidelines) to give me the opportunity to create a safe plan for my patient. Guess what? Frieda returned home, albeit with the support of many resources.
We need to constantly advocate for our patients, and now we can do just that, with tools and technology that didn’t exist a decade ago. I believe an optimal length of stay can be achieved with not only a carefully executed plan of care, but access to the latest technology and comprehensive medical and ancillary resources.
Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers.
Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination.
 J Gen Intern Med. 2015 Jun;30(6):712-8. doi: 10.1007/s11606-014-3155-8. Epub 2015 Jan 24. Increased Risk of Mortality among Patients Cared for by Physicians with Short Length-of-Stay Tendencies.