Hospital Length of Stay Initiatives & Post-Acute Support

Bryan Gargano, MD, FACEPAssociate Chair, Emergency Services &Associate CMO Patient Throughput/Capacity Management

Mark F. Klyczek, FACHEVP, Long Term Care Division

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Rochester Regional Health

2,500+medical staff

16K+system employees

87+primary care & ambulatory locations

5hospital locations

936long term care beds

8senior living facilities

370Kbehavioral health visits

54Patient lab testing sites

1M+clinical trials tests

245K+emergency room visits

1,600+system volunteers

RRH Introduction

• New York State Regulations

– CON State

– Local Health Services Agency

• No LTACH presence in Upstate NY

• Acute Occupancy typically > 95%

– ED Boarders, Floor Transition Spaces

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Who We Serve

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Style of System

• Relatively New (3 Years)

• Rapidly Growing and Expanding

• Matrixed Organization

• Financial Cost Allocation Silos

• Staff Vacancies

• ED Boarding and Lack of Inpatient Beds

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Do you have our problems?

• Significant ED Boarding?

• Inpatient transitional hallway beds?

• Seemingly long Lengths of Stay?

• More patients than hospital beds?

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Hospital Must Acknowledge

• Emergency Department Boarding is not an Emergency Department problem

• It is an indication that your hospital is queuing patients

• All volume is good volume

• Systemic solutions must be brought forward

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Hospital Capacity Management

• Focus on throughput issues that cross service lines

• Provide guidance for service line initiatives

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Clinical Optimization• CHF• Sepsis• Ortho - TJR• Neuro

Hospital Operations• Discharge Planning • Extended IV Antibiotic • Transportation Contract• Long Term Care

• EVS Bed TAT

Service Line/Program Leaders• Volume Growth • LOS Efforts• Clinical Protocols • Readmission

24 x 7 Hospital• Supply/Demand Analysis• Delays in Care

Identify and Advocate for ImprovementsOrtho TJR Initiatives

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2015 2016 2017

LOS - Primary Hips & Knees

Cases Avg LOS Goal (< 2 Days)

Linear (Cases) Linear (Avg LOS)

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Overall - Discharge to SNF

% to SNF Goal (< 20%)

One Step at a Time

• Spend time establishing metrics

• Understand what is important to your stakeholders– Initially all LOS

– Utilization Management minimized Observation

– Then Inpatient LOS• Ensure stabilization of LOC

– Don’t have blind spots: Extended Recovery, Outpatient in a Bed, Hospice, etc.

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Dashboards

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Next Steps

• Focused on throughput issues that cross service lines

• Metrics are established AND understood

– Goals are clear and measurable

• Look at your data for opportunities

– Use a metric that quantifies your capacity need

– Bed Days = LOS X Volume

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Discharge Streams

22,859

6,772

3,262

513 442 436 242 114 85 65 36 33 160%

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120%

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Pareto of Discharges by Disposition

Discharges % of Total

Data Source: ADT0162 from 1/1/17-9/30/17

Discharge Streams by Bed Days

55,131

38,690

32,806

6,4744,582

991 815 576 219 208 200 186 1650

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Home or SelfCare

Home w/Care

SNF Expired Hospice AgainstMedicalAdvice

PsychiatricHospital

Short TermHospital

Other ED Only IntermediateCare Facility

Transfer toAnotherFacility

Jail

Pareto of Bed Days by Disposition

Bed Days % of Total

Data Source: ADT0162 from 1/1/17-9/30/17

Discharge Disposition – Pareto Chart Bed Days in Excess of IP LOS Goal

Data Source: ADT0172 Throughput Summary Dashboard

Data Timeframe: 01/01/2017 – 02/25/2017

Quantifying the Barrier to Discharge

• Wasted Bed Days

– Manual Documentation in Epic by providers

– Avoidable Hospital Days

• Discharge barrier quantification

• Benchmarking

– Selecting benchmark and applying

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Hospital Initiated Improvements for SNF Discharge

• Value Stream Mapping Sessions

– SNF Selection Process

– Directed Choice

• Expectations with Metrics for Return

• Accountability with Utilization Management

• Automated Choice Expansion

• Transportation

– Lessons Learned

• Use as foundation to earlier discharge plan

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Hospital Initiated Improvements for SNF Discharge

• System Transfer Center

– Funnels and coordinates patient movement

• Upstream from individual hospitals

• Directs patients to hospitals with capacity

– Translates disparate communication into Acute Care EMR

• Enables SNF data to flow to ED and Hospital

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Support of Acute LOS Through Post-Acute Care

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Twitter Summary

The 936 bed LTC Division has improved quality and partnered with HCM. 2018 focus will be complex medical and clinical integration while improving ops.

MLTCGA!!

Composition of LTC Division

Clifton Springs Hospital

Extended Care

UnityLiving

Center

Park Ridge Living Center

Hill Haven Transitional Care

LONG TERM CARE DIVISION

Edna Tina Wilson

Living Center

Neuro –Behavioral

CareDialysisWound

CareDementia

Care Transitional

Care(Rehab)

Ventilator Care

Service Line Overview

Regional Post-Acute Gaps

• LTACHs not Operating in Our Region– NYS Regulations

– For-Profit Status

• Lower Acuity Housing Without Restrictions– Age

– Diagnosis

– Income

• Drives longer LOS for Acute & LTC Patients who do not require the respective services

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LTC Overall Occupancy Trends

Source: NYS DOH

RGH Complex Care Discharges 2016/2017

Utilizing Our LTC Asset

• Blood Transfusions

• Chest Tubes

• Complex Wounds with Plastics

• Hemodialysis & Peritoneal Dialysis

• Life Vests

• LVAD (developing)

• Milrinone

• Oncology

• Pharmacy Services

• Power PICC

• Respiratory

• Suboxone

• Telemedicine

• TPN

• Ventilator

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Current Services for Complex Patient Support

LTC 2018 - 2020 Focus

• Hospital Capacity Management

• Complex Medical Conditions

• Service Lines Support & Integration

• Primary Post-Acute Network Contact

• Improve Quality Within RRH Facilities

• Physician Recruitment

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2018 HCM Support Initiatives

• LTC Division/System Integration

–EPIC Implementation

–Telemedicine Expansion

–Collaborative Nursing with Acute Care

–Post-Acute Network Engagement

–Physician/APP Recruitment

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Imbedded LTC Coordination

• SNF discharges are a significant LOS challenge

• Census patients with a LOS >10 days

– Account for 64% of the patient days

– But only represents 17% of the total patients

• Completed gap analysis for SNF discharges

• Discharges to SNF require focus & knowledge

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Imbedded LTC Coordinator Initial Results

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LTC Placement Coordinator at RGH ImpactWasted Bed Days Reduction Jan - Oct 2017

Implemented 4/9/17

1Q17 Average: 167 days2Q17 Average: 119 days3Q17 Average: 109 days

Weeks

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ted

Day

s

IP LOS - 0 to 90 Day Discharge Groupings

IP LOS Grouping @ Midnight Census

Discharges to SNF LOS & Adjusted LOS for >20 Day LOS

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13.06

10.21

13.13

9.52

9.05

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9.699.73

11.39

10.05

12.12

8.84

9.89

8.66

9.349.15

7.34

8.07

10.85

9.92

10.58

12.10

9.72

10.04

8.32

11.38

12.53

9.499.69

9.07

11.03

9.57

10.34

9.62

10.81

7.38

8.37

9.27

7.76

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6.82

7.26

6.59

6.97

7.41

7.117.33

7.07

6.42

7.006.86

7.387.41

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6.38

6.706.706.55

7.997.93

6.967.076.99

6.24

7.82

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6.957.09

5.68

6.146.11

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7.71

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6.69

7.42

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All Patients Exc. Outliers Goal Linear (All Patients) Linear (Exc. Outliers)

Service Line Integration

• Current LTC Division Clinical Integration Opportunities:

– Orthopaedics

– Neurovascular

– Sepsis

– Cardiology

– Surgery

• Service Line planning beyond acute care

• Thou shalt not hospitalize a patient without a discharge plan

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Service Line Integration – LOS by Referral Date

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Service Line Integration – CHF LOS by Referral Date

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Improving Quality While Supporting LOS

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3545 3580

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5275 53655490

56155755

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Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Apr-17 Jul-17 Oct-17 Jan-18

CMS Reporting Period

RRH LTC Quality Measures Points ImprovementQ1 2015 - Q2 2017

Data Source (Equip & CMS.gov)

CMS 5 Star Ratings

FacilityHealth

Inspection Quality Measures Staffing Overall

Clifton Springs

DeMay LivingCenter

Edna Tina Wilson

Hill Haven

Park Ridge Living Center

Unity Living Center

Source (www.medicare.gov/nursinghomecompare/search.html) Updated September, 2017) = 2017 Gain

as of 10/10/17

Post Acute Network Development

Goals of Post Acute Network Development

• Create a reliable network of owned and community skilled nursing facilities to accept discharges from the 5 RRH acute care hospitals

• Reduce Hospital Length of Stay for Nursing Home eligible patients

• Reduce cost & increase quality care delivered by network facilities

• Develop services to support discharges and reduce readmissions

• Facilitate LTC discharges to lower levels of care

• Align incentives and opportunities with network facilities

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Post Acute Network Development

Align Incentives and Opportunities with Network Facilities

• LTC preferred facilities to join GRIPA, and/or LTC IPA

• Utilize GRIPA to manage the care of all LTC patients

• Network inclusion stabilizes referrals to LTC facilities

• Review potential for group purchasing and other cost reduction areas for community facilities

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Post Acute Network Development

Initial Inclusion Criteria

• Rochester Regional Health Owned Facilities

• Rochester Regional Health Physician Relationship

• Historical Volume of Shared Patients

• 5 Star Quality Rating

• Clinical Capacity

• Readmission Rate – EQUIP Measure

• Geography

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Post Acute Network Development

Proposed Dashboard Measures

• Hospitalization/Re-hospitalization Rates

• Response time to each referral – Curaspan

• 5 Star Quality Measures

• Payor Mix of Patients Accepted

• Number of Declinations

• Hospital LOS

• Cost per Patient Day

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Navi Health Hospital Dashboard

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Facility

Discharge Year 2016

Discharge Month Jul Aug Sep Total

# Vis i ts with a Referra l 4,723 385 421 420 3,719

# Referra ls 24742 1916 2371 4037 22243

# Bookings 3900 312 335 338 3040

ALOS-a l l referred patients 11.26 11.17 10.64 9.85 11.16

LOS when medica l ly ready at Accept

(accepted pts )9.89 9.59 9.69 8.64 9.89

LOS when not medica l ly ready at

accept (accepted pts )10.82 11.76 10.66 9.89 10.66

Accepts/Patient (that are accepted) 1.22 1.19 1.25 1.28 1.23

Avg. Referra ls/Patient 5.24 4.98 5.63 9.61 5.98

Hospita l Admit Time to Fi rs t Referra l

Target in days= 55.89 5.17 4.99 4.9 5.27

Referra l to Discharge booked patients

** Target in hrs= 6097.82 117.75 101.1 83.6 103.75

Avg.Time Referra l to Provider Accept

(booked Patient) ** Target in hrs= 2453.29 54.46 60.25 41.04 55.05

Provider Accept to Discharge(booked

patients) ** Target in hrs= 3641.53 66.29 47.29 44.36 50.02

Rochester General Hospita l

2017

Navi Health Hospital Dashboard

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Facility

Discharge Year 2016

Discharge Month Jul Aug Sep Total

Avg. Accept to Discharge when

Medica l ly Ready at Accept time30 33.11 32.94 31.22 30.58

Avg Accept to Discharge when Not

medica l ly Ready at Accept58.78 86.23 57.69 53.09 67.25

Median Accept to Discharge Booked

Patients23.17 25.37 23.04 24.67 24.2

%Referred Patients who were never

booked17% 19% 21% 20% 18%

Avg Medica l ly Ready to Discharge(Yes

va lues ,Care Connect)4.51 2.19 2.23 1.65 2.89

#>30 day Outl iers 280 19 19 17 204

% 30 Day Readmiss ions 19% 21% 19% 13% 19%

Avg.Accept to Booked ** Target in hrs=

1230.93 55.76 28.2 28.65 37.45

Avg Booked to Discharge ** Target in

hrs= 24 10.34 14.22 17.83 18.01 14.4

Rochester General Hospita l

2017

What if you don’t own a SNF Asset?

• Include the LTC Facilities in Service Line Planning– Break the divide between Acute and Post-Acute

• Invest capital in facilities willing to partner for throughput– Less costly and quicker than building your own

– Co-branding

• Partner with particular facilities for particular discharges– All facilities cannot provide care to all patients

– Capital and staffing intensive

• Assist with Clinical Education for particular patient types

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What if you don’t own a SNF Asset?

• Identify and correct discharge planning issues raised by Acute & LTC providers

• Consider a LTC focused position or team in care management to improve transitions

• Contract for Medical Directors, Attendings and APPs to assist with Transitions of Care

• Utilize Telemedicine

• Share information regarding risk sharing agreements & post-acute’s impact

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Key Take-Aways

• Prioritize & Resource Hospital Capacity Management

• Research patient types & discharge destinations driving LOS

• Determine the key metrics that support LOS Initiatives

• Although not perfect, Wasted Bed Days and LOS groups offer objective starting points for data review

• Clarifying who is responsible for each data point

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Questions?

Contact Information:

Bryan Gargano, MD

Bryan.gargano@rochesterregional.org

Mark Klyczek

Mark.klyczek@rochesterregional.org

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