I'd like to introduce our speaker to kick us off with part four today. Dr. Toni Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for more than 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short- and long-term clinical perceptions and outcomes. Thank you for being back here with us this morning, Dr. Sesta, and we invite you to go ahead and get us started. Terrific. Thanks, Lindsay. Good morning, everybody. You've made it to part four, module four. Congratulations. I was thinking as we ended up last week, Lindsay, how jam-packed the content has been. I have to kind of a little bit apologize for that because I know I threw everything but the kitchen sink into the last two or three webinars, but there is just so much. I guess that's why we call it a boot camp because we got to working real hard and real fast, and that's what it's all about. As we're moving through our roles and functions, if you remember, we did the first two basic ones already, utilization and discharge planning, and today is your third, care coordination. I call care coordination the forgotten role of case management. Why do I say that? I say that because certainly what we see is a much, much greater emphasis on utilization management and discharge planning. Those two roles are much more obvious to folks. They're clearer in terms of what to do, and they take priority most of the time. They're also time-sensitive. You usually got to get those discharges out in the morning if you can, ha-ha, and then your utilization reviews have to be in in a timely manner and all of that. That's why when we get to this role of care coordination, it becomes a little less clear maybe and a little less of a priority, but I'm here to tell you it is one of our fundamental roles in our best practice models. Why is it so important? Well, I say it right here. We want to manage length of stay and cost of care, and we certainly know that length of stay isn't so easy to reduce anymore. As I think I may have a slide later, there's really no more low-hanging fruit when we look to reduce length of stay. We've chipped away over many, many years, and so our average national length of stay, as we discussed in Module 1, is about 4.6 days right now. But that's inclusive of everything, so that includes your very long stay patients. It includes Medicare, which tends to run about an eight-day length of stay, so it's all in, and so you've always got patients where there's opportunity. The question becomes, how do I get at that? How do I do that? When I look at length of stay, yes, by reducing length of stay, I do save some dollars, but I can save dollars in other ways as well. So let's start off this morning by talking about what care coordination actually is, and these are a couple of explanations from AHRQ, and that's a quality organization, and they said a couple of things that I think are helpful to us in understanding exactly what we're talking about today. So care coordination involves deliberately organizing patient care activities and sharing information among all the participants concerned for the patient's care to achieve safer and more effective care. So organizing patient care activities, and I've alluded to that over our prior webinars kind of coming up with a plan, and we'll talk more about that. And then sharing information, communication among the team members, obviously, and as I've said before, and you've heard me say, interdisciplinary rounds is the most effective and efficient way to do that. And then they go on to say, this means that the patient's needs are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient. So in that sentence, I think it's one sentence, yes, we're talking about planning prospectively, not waiting for the day to fall in front of us, but the plan for the day, the plan for the stay. What does this patient have to achieve? What outcomes do we have to achieve to move this patient toward a safe and appropriate discharge? And so working with the team, getting everybody's input becomes a critical part of that. And so case management is all about care coordination, effective care coordination. Yes, we are, or we should be. It's the core business of hospitals. If hospitals just allowed everything to kind of run by karma, well, okay, the doctor rights and mortars and things will just happen when they happen, and frankly, that's how it used to be. We wouldn't all be in business very long, but it's also a core responsibility of our case management departments, because it is one of our principal roles. So we've looked at these roles before. I put care coordination at the top for today, because that's our main focus, and we've talked about utilization and denials and avoidable, well, today we'll talk about avoidable delays. We've talked about discharge and transitional planning. Next week we'll talk a little bit more about quality and psychosocial assessments. So embedded in all this stuff that we do is care coordination, not something really to be taken lightly or just avoided. So what's the purpose of care coordination? To optimize each day that our patient is in that acute care setting, and that, to the extent possible, includes evenings and weekends, and I know evenings and weekends are such a challenge for most of you. I really do understand that, and we'll talk more about how to kind of deal with that. Manage care interventions that the patients require to occur in proper sequence. So that's the facilitation piece. We have coordination, and we have facilitation, I'm sorry, that's the coordination piece. And then the facilitation pieces facilitate the interventions to ensure that they occur in a timely manner and without delay. So to me it's kind of two-pronged. One is knowing what the patient needs, what does that patient need, and then making sure that it gets done. So that's the purpose of this role. We know that when care coordination is good, it can improve patient safety, it can improve quality of care, and operational efficiency. So operational efficiency is what drives better lengths of stay and reductions in cost of care. Why do we care about length of stay in the first place? Well, clearly we all know that if length of stay gets shortened, there's the potential for shortened costs for the stay. But I can tell you, because I've studied it, that when you look at a patient's length of stay, the vast amount of dollars spent on that stay are spent in the first 24 to 36 hours. And assuming after that, that the patient is on a trajectory toward discharge and does not have an acute event, like a cardiac arrest or a return to the operating room, that's where those dollars will be spent. So when we carve off a day, let's say, on the end of the stay, that's good, don't get me wrong, it affects our average, but it's not really saving a lot of dollars. So that's why we want to look what's happening in between during all of those days. And we care about length of stay because, as we've talked about, most of your payers, of course, your Medicare and Medicaid are paying by a DRG or a case rate, but a lot of your managed care contracts are doing so as well. So like I said, when you're in a case rate contract, you're getting a flat rate for that stay, and it's up to you, the hospital, to optimize those dollars as best you can. We also know that the longer we keep a patient in the hospital, the more likely something unplanned and untoward will happen. Length of stay is publicly reported now, it's transparent for anybody and everybody to see. It gauges hospital efficiency, as we've said. And then when you've got a really efficient hospital, you're going to attract perhaps better, and by better, I mean better pricing on managed care contracts, maintain a competitive edge, align with regional as well as national benchmarks, and now, of course, value-based purchasing, the efficiency measure, also known as the Spending per Medicare Beneficiary Measure. So I broke this next couple of slides into two parts. What impacts... Uh-oh. Oh, dear. Lindsay, can you hear me? I can. Yep. My screen just went black. I'm sorry. Uh-oh. Yeah, it's rebooting itself. Oh, man. We can still see your slides. You can? Okay, that's good. I can't. I'm logging back on. That's funny. No worries. We'll take just a quick pause here. Okay. While we're doing that, for those of you who joined us just a few minutes after my initial introduction, if you have questions for Dr. Sessa today, we encourage you to interact and engage with us. And you should see that Q&A option there at the bottom of your Zoom window that you can utilize to type in questions. And if you don't see that, then you can, of course, utilize the chat as well. So please feel free to engage with us today. This is wild. Technology at its finest. I'm telling you, I'm just talking, and it just went completely black on me. Thought I could do a shortcut, but nope. Microsoft Edge closed unexpectedly. Restore. Let's try that. That would have been too easy. I'll be right in in one second. No worries. We'll take just a quick pause and get you set back up here. Good morning, Teresa and Trish. I see your comment there in the chat. Thanks for joining us today. Now I hope this doesn't, my slides aren't showing here, Lindsay. I can see your screen there, Dr. Sesta. Yeah, but you don't see the slides, right? No. Are they up at the bottom of your Zoom window? Yeah, let me open them again. It's time for questions. Okay, we're done. Okay, that was fun, everybody. Thanks for coming. Okay, what do you see now? Here they are. Yep. Where was I? Eight, I think. Okay. Is that good? That's it. Okay, let's all pray that doesn't happen again. All right. So I was talking about expected length of stay versus actual length of stay. Expected length of stay is kind of tricky, and I know some of you may use, you know, what do we call it? An estimated DRG on admission or an estimated length of stay. Working DRG was what I was trying to think of. But there's some limitations in using a working DRG because, as we know, the DRG is assigned after discharge. The codes are assigned. We may get credit for complications or comorbidities. The physician documentation will impact on that. And then if you have CDI, they're also going to be impacting on the physician's documentation. All of that feeding into whatever DRG is finally assigned to that case. And we know that when we use a working DRG, it doesn't always align. I think it only aligns with the final DRG about 30% of the time. So how do I use an estimated or expected length of stay, then, on admission? The best way, in my opinion, to do it, I know it's a little more cumbersome, but you can use an estimated length of stay based on the physician's presumptive diagnosis or surgical procedure. For a surgical procedure, it's a lot easier. Even with a presumptive diagnosis, a physician should have some sense as to, again, complications aside, should have some sense of the expected length of stay for this admission. They really shouldn't. If they're not thinking that way, then that's unfortunate because they really should be. So kind of thinking about not the admitting diagnosis, but what actually is the patient is going to be worked up for, treated for, in combination with a conversation with the physician, will give you a much better sense of the expected length of stay, hopefully. Which is different than what impacts on the actual length of stay. And there's so many things that impact on that actual length of stay. So, obviously, care coordination and patient flow. We hear patient progression, patient flow, lots of different terminology out there for what I call coordination of care or care coordination and facilitation. What actually impacts, again, would be the process that you all use or don't use for coordination of care. I can't tell you how many times I go into a hospital as a consultant and I say, who's coordinating the care? And nobody's coordinating the care. It's either not on their radar screen at all or they don't really understand it or they don't have time because of the way the staffing is in the department. You know, lots of different reasons. Physician practice patterns clearly impact on the actual length of stay. Getting those consultations done in a timely manner. The availability of those ancillary services. And, again, let's think about our weekends and evenings where services are less available. Timeliness of tests and reporting, so getting the tests done, getting the report back. And ability to schedule procedures and tests timely. And that's variable and that may depend on what kind of a test it is, which department is doing the test. And there's other stuff, too. There's those avoidable delays, which we'll talk about. Ineffective or effective discharge planning, either going to help or not help. Unfunded and underfunded patients with minimal resources. So when that patient doesn't have any coverage for post-acute services, that's obviously going to impact on that patient's actual length of stay. And even geographical challenges, getting post-acute resources. If you're in a critical access hospital or in an area where maybe there's a shortage of a particular service, like physical therapy, you're going to have a problem. Maybe that patient will have to stay a little bit longer. Effective communication and, again, conversely, ineffective communication. And then, as I've mentioned before, not staying focused on the reason the patient was admitted to the hospital and going down all kinds of rabbit trails and giving tests or other things that could be done on an outpatient basis. So let's start off with cost. Cost of care is an interesting thing. And until I really started thinking about it a few years ago, I had difficulty conceptualizing what it really means for us. And believe it or not, I came up with a restaurant analogy. But the analogy could apply really to any business when you get right down to it. So you go to a restaurant and you order a meal and you get a bill. You eat your meal, you get a bill. And that bill, you know, maybe you paid... Of course, I'm in New York, where we spend a lot on food, unfortunately. I'm sure you do, too. Restaurants, especially. So I go in and I order a steak. Let's get fancy. And a baked potato and a vegetable, and I have a cocktail. And, anyway, I get a bill. If I went to the supermarket and bought that steak, it might be, you know, $8 or $10. The restaurant's charging me $30 or $40 for that steak, and so forth. Well, the same thing happens in the hospital. And this is why when patients get bills, they get confused and upset. And I can't say that I blame them. But if you think about it, embedded in that bill for that patient is, just like our restaurant, the cost of the building or the leasing of the building, the rent, perhaps, the insurance on the building, the heat, the lights, the staff, and so on and so forth. Well, the same thing applies in a hospital. And so when a patient gets a $20 bill for two aspirin, of course, I think I'm exaggerating a little bit, the $20 isn't really just for the two aspirins. It's for the pharmacist and everybody else who has to touch those two aspirins. And the process of dispensing those two aspirins to your patient is all embedded in that cost. So the question becomes, how do I tease out all those different costs if I want to reduce costs? Because if you want to reduce costs, you have to understand what the cost actually is before you can attempt, in my opinion, to reduce it. So I just thought it might be helpful just to talk about cost accounting. Now, some of your hospitals may have true cost accounting systems, and many of you probably don't. They were very popular, I'm going to say 20 years ago, a lot of hospitals were purchasing them. They kind of fell out of favor when people felt that the data in them wasn't accurate. I have not had that experience. I have had excellent experiences with cost accounting systems and found them very useful for projects where we wanted to reduce costs. So these systems record, analyze, and allocate costs for individual services provided to a patient. So what does that mean? So if I go into a cost accounting system, I can tell how much was spent for this medication, for this patient, rather, on medications, procedures, tests, all of that stuff. I can actually break it out, because maybe I'm looking at the use of chest X-rays for a particular diagnosis. I can actually look at that. Now, if you don't have a cost accounting system, how do you do this, then? Maybe you still want to do it. You still want to understand your cost, but you don't have a cost accounting system. So if you don't, your finance department probably uses something called an RCC, Ratio of Charges to Cost. And that's essentially dividing the charges, which are always inflated, against the actual cost. Because that gives you sort of a less accurate, but somewhat helpful measure of true cost. If you look at charges, it's not really telling you true cost. Because again, it's that $20 for those two aspirins. But I want to know what was embedded in all of that, in that $20. So for measuring, the cost accounting is needed for all of our value measures, certainly if you're in an accountable care environment, you need it. Opportunities to reduce cost, as I said. To bring together financial and clinical outcomes data. To me, that's so exciting. Because the finance side, their data, but how does that impact? How does all that cost, how does all that information about cost, and where it's being spent, impact on the clinical side? So it allows us to bring these two worlds together. And they do need to be brought together in our environment to help us negotiate appropriate rates. This is another thing. Think about it. Somebody in your organization sits down to negotiate a managed care contract. They don't even know what your true cost is. And the managed care organization says, all right, we're going to give you x amount. And here you go. And you go, OK, great, thanks. You don't even know if that actually aligns what your own true hospital cost is. So that's another reason why it's important to know your true cost. And you want to understand total cost of care from inpatient and outpatient. Because remember, we've got those bundled payments. We've got the spending per Medicare beneficiary measure. We've got lots of different payment methodologies that require that we think across the continuum better than we have before. Also, understanding cost helps us understand value. You may hear the value proposition. Well, I'm going to give you the value proposition, because I do think it's important. Health outcomes achieved per dollar spent. So how much does it cost us to get to these sets of patient outcomes that we're trying to achieve? And so therefore, when you talk about value in health care, you're talking about the cost of care. You're talking about defining it around one patient. So it's not volume. And unfortunately, our system is still driven by discharges. The more discharges, the more revenue, unless they're denied, of course. But when you look at value, you're looking at the cost of achieving a set of outcomes, not just the number of discharges. So it's a little more sophisticated way of looking at it. So the equation, then, value equals outcomes divided by cost. Outcomes divided by cost. How much does it cost me to achieve those outcomes? And good value in health care encompasses efficient care and care coordination. And again, relates to the patient's total cost for a cycle of care. So cycle of care can be defined in a lot of ways. So in a bundle payment, remember, a lot of the bundle payments do transition and follow costs in the post-acute world, as we've talked about. So that's the cycle. It's defined by the bundle. The efficiency measure measures you 30 days out after discharge. An accountable care organization, depending on how they're defined, may include inpatient and outpatient costs. Or it could be inpatient only. And looking at outcomes divided by cost gives you a framework for reducing costs based on the true cost versus those outcomes that are achieved. OK. So that's all I'm going to say about that. But I do think it's important to at least have a general understanding, because we're going to go on and talk more about cost and length of stay and how that sits in the system. So I'm not going to go through all of that. But I do think it's important to have a general understanding of cost and length of stay and how that fits together. So actually, yesterday I was thinking of changing this to 2025, although all the metrics are the same, because October 1st we went to our new fiscal year. But I'll leave it like this for the moment. I did leave it like this. So we are still looking at 25% for your value-based purchasing outcomes, which includes mortality and complications, 25% for safety, 25% for, I love it, person and community engagement. That's very, very serious. HCAHPS, and 25% efficiency and cost reduction. And that's the one that you and I are most interested in. Because I believe, yes, we can certainly impact on HCAHPS scores. But I think we have the biggest opportunity in case management in efficiency and cost reduction. So I've mentioned the efficiency measure or spending per Medicare beneficiary. So this includes your Part A and Part B spending and starts three days before your patient is admitted to the hospital and continues through 30 days after discharge. If in that time period, which could be up to 33 days, there's a transfer of that patient or readmission of that patient, that is included in that total cost. And it's the total cost that's going to give you your score. So it's a lot to think about. Now, when they started the efficiency measure, they started with one. I don't know if you remember me mentioning that the first DRGs, when they put in those relative weights and we say, well, what is it relative to? It was relative to arbitrarily 1.0. They could have picked 2.0, 2.5 as the pivot point. They picked one. They did the same thing for the Medicare spending per beneficiary scoring. They picked 1.0. But initially, everybody did a little bit better. So what did they do? They are now scoring us on a curve. So they dropped it to 0.99. And that's based on national averages. So as far as this score is concerned, lower is better. So if you happen to have gotten a 0.85, that's 14% better than expected or less than expected. Higher is worse. You don't want to be higher than 0.99. So if you're 1.10, you're 11% higher than expected. And you can certainly check your own hospital scores on Hospital Compare. So it also includes, as I said, care providers, care rendered to your patients up to three days before the patient's admitted to the hospital. So the patient may have gone for some testing and then brought them to the emergency department. All that's included. And then any care provided up to 30 days after hospitalization. If their care continues beyond 30 days, it's not included. But up to 30 days, and God willing, they're not going to be that long. Well, they could be receiving rehab. It's possible. Stakeholders also include your patient and family and their roles and their participation in their own care. Internal costs affecting your spending per Medicare beneficiary. Your care providers, how efficient are they? How well are they at coordinating care along with you? Delays in service. Services you can't get done in a timely manner. Over-utilizing, so ordering things that don't need to be ordered or they're redundant or unnecessary. And again, there's our patient and family because they're part of the team. They can help and they can delay. So how can we improve our spending per beneficiary scores? We use best practice care coordination in order to do that. Yes, the doctor writes the orders. Yes, the doctor controls, so to speak, you know, the resources consumed for that patient. But we have an obligation as case managers in our performance of care coordination to question over-utilization of resources. We also have an obligation to question under-utilization of resources. If we see a delay in a physician ordering something that patient needs, for example. We want to focus on successful and efficient care transitions for our patient as we talked about. Good transitions may mean less resource consumption at the next level of care. Having strong, hard-wired, multidisciplinary teams. That's a prevailing theme throughout this bootcamp. Managing discharge planning efficiently and effectively. Manage to keep the patient out of the hospital once discharged, and that has to do with readmission reduction and aligning with your next level of care providers, of course, as we have discussed. So, what are some of those elements, then, of best practice care coordination? I probably, frankly, could have written a lot more, but I think these are your big-ticket items. So, establishing accountability and agreeing on responsibility. So, when you stand together, as I envision you do, having an interdisciplinary team, rounding process of some sort. Who's accountable for what? Each team member is accountable for something, and that person has to own that. And then responsibility. So, this patient's delay getting their CAT scan done, who's going to take responsibility for looking into that? So, that is something that has to be communicated well in order to improve your care coordination. So, I think you can't really talk about care coordination without talking about good communication and sharing amongst the team members. Helping with transitions in care is part of best practice. Assessing your patients' needs and goals. Now, yeah, we're required to do that, but you need to know what they are before you can coordinate them, right? Creating a proactive care plan. So, on admission, we begin that process by assessing our patient on admission and coming up with a plan. Monitoring and following up. So, that means daily reassessment, and I know people say, we don't have time. Well, that gets to models, which we'll talk about next week. So, many of you are understaffed, although I do see that that's starting to get better. It has taken decades. So, I'm sure some of you struggle with that issue still to this day. And so, it becomes difficult to do some of these things, but they are so important. So, responding to changes in your patient needs, supporting the patient's self-management goals. Again, I'm not saying that you can't do that. I'm just saying that you need to be able to do that. And so, I think that's important. So, I'm not saying that you can't do that. I'm just saying that you need to be able to do that. Self-management goals. Again, helping patients self-actualize to the extent that that's possible. Linking your patient to community resources and aligning resources with patient needs are some of the things you want to think about. These are things that are in your mind as you're going through the processes. So, let's talk about how to do this in the real world. So, case management's role in care coordination. So, if you think about the patient comes into the hospital and they're going to go through that acute continuum until discharge. They might come into the ED, spend some time in the ED, hopefully not too much time, and then move to an inpatient unit. So, what we do in care coordination is manage all those sub-processes that support that patient as they move through that continuum. So, tests, treatments, procedures, the usual things that we talk about. Consultations, always a thorn in everybody's side, and any other care interventions that need to get facilitated. So, we know what the plan is, and then we need to coordinate and facilitate that plan. So, we've talked to the doctor. We've looked at the medical record, and hopefully the doctor has told us what he or she expects to accomplish during this hospital stay and how long they think it will take them to accomplish it so that we can help get that organized and coordinated and then make sure it gets done in a timely manner. So, assess every patient on admission. I know it's hard, but you have to do it anyway. You have to do it under the conditions of participation. Well, you know, we can pick and choose patients, but it really makes more sense in today's world to do that assessment on every patient on admission. Next week, we're going to look at a sample assessment tool that meets all the regulatory requirements that we've talked about. Making early referrals as needed. So, front-loading your process, making sure the patient gets everything they need, but they get it as soon as possible. Reassessing daily. That doesn't mean you fill out a form or any of that stuff, but if you have interdisciplinary rounds, it's a great way to hear from your other team members and also for you to share that patient's progress, care progression, and understand what may or may not have been accomplished for the prior 24 hours and adjust accordingly. Expediting or facilitating test treatments procedures. You know, frankly, yes, I say proactively manage length of stay, but when you do all this other stuff, you are, by default, managing your length of stay. Identifying that anticipated discharge date. Again, that's going to come from that early conversation with that physician about what the plan for the stay is. And creating that plan that outlines the key interventions and outcomes to be achieved each day. And, wow, those can actually go on the whiteboard in the patient's room. And then when the team gets together, coordinating among and between the team members and you're discussing all that has gone on by discipline. Talking with your other physicians, maybe specialty nurses, home care agencies. You've got to do that in a timely manner. And, of course, getting with that family and family caregiver and patient on the day of admission, if possible. If the family's not there on the day of admission, well, hopefully eventually they'll come in or you can call them and have that conversation. But you want to do that early and fast. And then identifying delays in your patient care progression and intervening to correct them. So that's a two-fold. Okay, I see that something's been delayed. I've got to jump right in and try to correct that. That's the foundation of care coordination. Goals. We want each day that the patient is in the hospital to be optimized. By that I mean that whatever's supposed to be getting done gets done and that the patient is being treated at an acute level of care. For those of you with per diem managed care contracts, when you come to the weekend and that patient has become custodial in a way, meaning that you're really not doing much for them, there's no tests, treatments, procedures scheduled for this patient, there's no IV treatment, nothing. So the patient is really just there in those days at risk for denials. And you really, you know, just from a length-of-stay management perspective, patient safety perspective, that's not really great. And I know sometimes you can't avoid it. But the question becomes, does that patient really need to be in the hospital? The plan of care is expedited. Barriers are identified and corrected. And by doing this, you have a better control of what resources. So it's a very active process care coordination. You can't expedite things. You can't identify gaps or delays if you don't know what the plan is. So it kind of all, you know, goes back to that. And again, byproducts of all of this, patient care is provided in a timely manner, patient moves as a smooth move through the continuum. So it starts with an assessment. It starts with then a plan, and then optimizing each day and identifying gaps and delays and correcting them. I mean, that's it. Yes, easy to say, right, Dr. Sesta, but maybe a little more difficult to actually do. So I put care coordination in the middle here, but we've got a lot of stuff kind of pressing in on care coordination, as we've mentioned the physicians and the physicians' participation. And if you have a hospitalist, as I've said, I think a hospitalist gives you a better shot maybe at working closely in terms of coordinating and facilitating care. If you have a community-based physician, maybe it could be a little bit more difficult. Patients and family and family caregivers can be your best friend in terms of care coordination, but they can also sometimes create barriers for you. Next level of care delay, yep, so again, resources in the community, availability of insurance coverage for, as we talked about. All of the hospital delays that can really snag your patient's movement. Your department itself, you're understaffed. Maybe you have a skeleton crew on the weekends. Maybe people's roles and functions aren't really quite clear, and so everybody's... Oh, my favorite was I went to do a consultation with the case management department, and they said, oh, we have rounds in the morning. I go into a conference room, and the room is filled with the RNs and the social workers. They take all the new admission sheets or whatever, I guess they were face sheets, I don't remember, and just threw them on the table, and everybody just grabbed one. What does that tell me? That tells me that the nurses and social workers are doing exactly the same work, or at least attempting to do exactly the same work, that there's no thought about that, and that you could wind up on any unit. You're not unit-based when you do it that way, so I hope nobody on our call today is doing it that way. And then, of course, the payer and regulatory requirements that can impact on your care coordination. So I've mentioned patient progression, patient flow. What patient flow gives us is a process for looking at, well, I'm using process again, a structured way, okay, of looking at all the processes that support a patient as they travel through their health care experience. So think of patient flow as a tool to manage costs and length of stay. So it's another tool in your toolbox to help with care coordination. It directly links to care coordination. It's a tool for managing length of stay and cost. For identifying avoidable delays, another tool for managing length of stay and cost. Patient flow is important because of rising bed demand and limited treatment capacity. So, you know, when that patient stays that extra day and what have you, then, you know, you may have patients waiting for beds unnecessarily. And that does not improve customer service and the patient experience, certainly. So bad flow, bad patient flow, can also result in poor quality of care, giving unnecessary medications or treatments, misusing or overusing product and personnel resources. The cost of delays. Think about when that patient can't get that vascular study done until Monday, when you're ruling out a DVT and now the patient's going to stay till Monday on IV heparin, and it turns out on Monday they didn't even have a DVT. I mean, just think of all that cost and waste. Patients going elsewhere due to dissatisfaction. So, yes, here it is. Length of stay is short. There's no more low-hanging fruit. So how do you chip away at what is already a fairly short length of stay? The Southern California Hospital Association gave us these metrics. They said 15% to 20% of admissions and readmissions are unnecessary, and I think that's been more than substantiated with the data from CMS regarding specifically readmissions. It's probably even higher than that, but they're talking about all payers. 20% test and treatment delays. Excuse me, I got a tickle. Excuse me. And, again, I think that gets to everything we've been talking about today. 10% to 15% extra days related to lack of home care availability or arrangements, beds, other post-acute resources. 50% physician practice and custom. Well, this is the way I do it. This is my thing. Now, we're chipping away at that with hospitalists, hopefully, but we still do see some of that. So when we talk about those processes and we want to look at the flow, we can break it down into access, throughput, and discharge. I hope you like my buckets. This slide's not quite as pretty. I tried to pretty it up, but I'm not good at it. So access, your admission process, your registration process, your pre-certification process, how patients flow through the emergency department, how the transfers get in, how do you do utilization review and bed tracking. Well, we've touched on some of these, certainly when we talked about utilization management and we looked at denials, and we saw a lot of registration denials adding to – I'm sorry, registration errors adding to registration denials, and so we see that there's huge opportunity there and just dovetailing that with your own admission process, and the same would apply in the emergency department. And then we had talked two weeks ago about how do we conduct utilization review on admission, whether it's the ED, whether it's planned admission, whether it's a transfer, how do we cover all those different areas. So for your admission processes, yeah, we have registration, I think is the big ticket item there. We can see that downstream. Yeah, it affects denials, but it also affects your ability to do your job because if you have the wrong insurance information from the beginning on that patient, well, that's going to cause some issues for you as you're trying to plan the patient's discharge destination and so forth, and circling back and all the issues associated with that. And then what do we do with some of these others that bypass us, you know, somebody who goes directly to a bed, let's say, and we get to them a little bit later. Now, I call it bed tracking. Some of you may call it patient flow meeting that you have in the morning. I've seen that. I'm not convinced of the effectiveness of those where some senior leaders sit and look at a tracking board. I'm really not clear on that, but I think something of that sort is helpful, making sure you've got environmental services present. It's hard to know at 8.30 in the morning who's going home that day. You may know from yesterday who's going home today, but, you know, it gets a little difficult to orchestrate. Do you have a bed board, an electronic bed board, or do you do it manually? So many of us now have electronic bed boards. Do you have somebody that, if you're a big enough hospital, do you have somebody who's managing for, let's say, every admission and discharge and looking at available beds and things like that? And what are your hours of coverage if you are doing that? So, again, our pre-admission, transfer, utilization, review processes become very important in patient flow, too. We want to manage the two-midnight rule, right? We want to get the patient in the right level of care, right, from the start. Access point case management, the ED, but also who do you have looking at those planned admissions and transfers? So we call that access point case management. It could be one person, two people. It really depends on the size of your organization, how many transfers you get, and so forth. Pre-certification management to prevent denials, obviously. Appropriate levels of service, as we said, and observation and how do we handle that. So if you really want to dig down, and your ED probably keeps the, in fact, I would say for sure, they keep these metrics because they're required to do so, and I'm not suggesting as case managers we have to worry about each one of these, but we need to understand that there are timeframes associated with registration and triage, and then we interject ourselves right there in the second bullet, management of the two-midnight rule, and what happens is sometimes the physicians in the ED are going to say, oh, well, you know, you're going to slow me down if you want me to stop and think about what level of care, and I have to maintain my length of stay short in the ED. Well, case management must interject itself, and it really doesn't take that long, working with that physician to come up with a decision about observation versus inpatient, and we must intervene, and that's what I mean when I say we have to optimize and use that two-midnight rule right at the point of entry to the hospital. Turnaround times are kept by your ED staff, and I just thought I'd mention it. It's kind of an interesting point. They look at the treat-and-release times from entry to disposition determination and then from disposition determination, be it an admission to bed assignment and then bed assignment to the floor. Now, in some ways, we can help expedite some of these things because we can help initiate treatments in the ED or get tests done in the ED, and also communicating consistently with the patients also helps with patient satisfaction. I found this information just recently from JAMA. It was published in 2023, but I just thought I would share it with you. Inpatient mortality rates among patients held in the ED. So when we say, you know, patient flow improves quality of care, here's some examples of where that might actually be so. ED patients had higher rates of mortality when they spent the night in the ED. ED patients had more adverse events and greater length of stay versus patients on inpatient units. Now, to me, that has to do with the fact that, as I've said many times, the emergency department staff are focused on emergencies, and once that patient is sitting in that ED and not going to an inpatient bed, they're kind of not a great focus for the ED, and I don't mean that as a criticism. It's just the nature of an emergency department. It has the word emergency in the title. Increased inpatient mortality rates were seen among ED patients who needed daily living assistance. Subsequent sleep disruption in a crowded ED can further exacerbate the risk of death and adverse events. More than 90% of EDs in the United States report overcrowding to be a problem, although there are usually enough empty beds to support patients under staffing can contribute to overnight stays in the ED. So this has all to do with getting that patient out of the ED and into an inpatient bed, and that's where we can really help. So I think we could... You know, I've been using the word chip away a lot today, but once again, this is an area where we can make an impact. Okay, so throughput. Now, when you think about the whole length of stay for a patient, I think throughput is probably where the greatest opportunities lie in terms of managing cost and length of stay. Pharmacy turnaround times, orders, meds to the floor, chemo and IV use. And do you guys have a meds-to-beds program? Some of you may. I'm seeing it's becoming more and more popular. And this has less probably to do with the pharmacy and maybe a little bit more to do with discharge planning. However, you have to have a dispensing pharmacy in order to have a meds-to-beds program. That means that pharmacy would fill prescriptions for outpatients. If you don't have a dispensing pharmacy in your hospital, then it's going to be much harder to have a meds-to-beds program. So what is a meds-to-beds program? Once the physician has written the discharge pharmacy orders, then we optimally like to get those meds to the patient before they leave the hospital because that increases the likelihood that they're going to actually take the medications when they get home. And studies show that a very small percentage of patients actually fill those prescriptions in a timely manner. So beds-to-meds has become important in terms of improving in that piece and reducing returns to the ED. Radiology is a big one. I talk about radiology a lot because I think it's where many of the most important tests are conducted and where we can see some delays. So what's our turnaround times for tests, treatment, procedures? And you need to have a general idea, and I'm sure you do. So for a CAT scan, for example, from the time the physician orders it, what's the expected turnaround time for that CAT scan to be completed? And when it isn't completed in that expected turnaround time, it becomes an avoidable delay. So we kind of need to know. And usually we do know, at least anecdotally. But you leaders, you can find out from your radiology department what their expected turnaround times are for some of your bigger ticket items and then work around that accordingly. And then turnaround times by location. We typically see the ED test treatments done more quickly than inpatient because the ED gets priority. Scheduling and weekends obviously are issues, and transportation can be issues. Getting the patient to the test and picking them up afterwards. Laboratory turnaround times. I think, you know, for the most part we're doing well except in one area, and that one area I want to mention is blood work for discharged patients, patients being discharged today, getting that blood work done and back in a timely manner. And nothing makes me crazier than when the doctor writes an order for something and the result doesn't come back until 11 or 12 o'clock and then there has to be an action from the physician based on that and then finally a discharge order. And so what can we do with our laboratories to expedite that kind of blood work? And so there are ways to flag in our systems these days and not to call them STAT. Because when we call everything it's called STAT, everything becomes STAT and nothing becomes STAT. So what you really want to do is have some electronic flagging process, this is a patient who's going to be discharged today, and to expedite that blood work to expedite that discharge. There's a project. Environmental service is so important, so important to patient flow. I can't say enough about it, so, so, so important. Are they staffed and scheduled correctly? I love it when we've got, you know, full staffing from 7 a.m. to 3 p.m. And then we go down to three people after 3 p.m. and when do all your discharges and admissions happen after 3 p.m.? You know, staggered staffing for environmental services, working with them so that, you know, you do have staffing when you need it based on your discharge times. How does that relate to your bed control staff if you have them? How long does it take to clean a bed and get notes? Now, a lot of that's electronic now, which is great, but I remember the days when, you know, a bed would be empty for some time because nobody reported it because nobody wanted an admission. Ooh, did I say that? But it's true. Transportation, well, when we talk about social drivers of health, we've got a new term embedded in there, and it's called, you know, we've had food insecurity, now we have transportation insecurity becoming an issue for a lot of patients. We can get them out of the hospital. Maybe there's delays in getting them out of the hospital, but where patients get into trouble, and this is kind of an aside from today's topic, but what's happening in the community is patients can't get back to see the doctor, can't get back for their physical therapy outpatient appointment or what have you because they don't have anybody to bring them, and they can't afford a taxi or some other Uber or whatever it is. So transportation insecurity, again, an aside, just thought I'd mention it, but your own internal transport delays and timeliness associated with those and then delays in getting ambulances, to the extent possible, try to order them the day before. If you use some kind of a shared ride, and everybody calls these something different, but, you know, if you have multiple patients going in one vehicle, particularly that's used a lot for Medicaid patients, if you have such a service, you know, those can be low. And now if you have a large number, a large surgical service and you're doing a lot of surgeries, your perioperative flow process is important. I mean, it's important anyway, but it doesn't really warrant a case manager unless you've got enough volume to support that. But if you do, you want to look at your pre-admission testing as your patient flows through all these sub-processes, your OR turnaround times, how quickly does an OR get cleaned and turned over, PACU turnaround times, cancellation rates and reasons and booking process. So when you've got a delay, let's say in the ED, you've got a delay in discharge, let's do it in reverse. Delay in discharge means you've got beds that aren't available to bring patients out of the ICU. You can't bring patients out of the ICU, so they're stuck in the PACU. They're stuck in the PACU, you can't move them out of the OR. And you start to see how that really affects the throughput all the way back to your operating room. And when a patient has to stay on the OR table, a physician has to stay with them. So it really just kind of messes everything up. So in this example, discharge timeliness is important, getting people out of the hospital in a timely manner, and to what extent case management can help facilitate some of this stuff. And good old physician practices, those practice patterns that I mentioned before, the use of interdisciplinary rounds, the physician's own length of stay, maybe overuse of ventilator, and I don't mean that the patient didn't need it, but how long they stayed on it. End-of-life issues that either aren't addressed by the physician, aren't clear to the family, haven't had that crucial conversation. Discharge and transfer issues associated with a physician, and critical care and telemetry bed usage. A lot of times physicians will ask for the patient to go into one of those areas simply because they want that better nurse-patient ratio, not because the patient has a clinical need to be in a telebed or critical care bed. Again, we have to intervene on those kinds of things. Okay, discharge. So we have all these different things, MD orders, discharge destination, financial issues, family, transportation, discharge planning process, and goodness, we've talked about so many of these today, and we've talked about some of these in prior webinars. So let's look at the actual discharge planning process and how it affects patient flow. Staffing, staffing, staffing, staffing. Doesn't it always come down to staffing for us? If you've got not enough people to do a lot of work, you're going to have delays. So staffing and then communicating daily, starting on admission with the patient and family, and then what are your discharge patterns? I still see this. It boggles my mind. On Friday, the hospital cleans out. How can that be that every patient suddenly met their discharge criteria on Friday? Well, we know that's not true. So how can we better get patients discharged when they're ready to be discharged? Maybe it was Thursday or maybe it's going to be Saturday, but that physician doesn't want to come in over the weekend. I mean, it's really unconscionable when you think about it. So you want to have better staggered discharge days that align with when the patient is ready to be discharged. Time of day, 2 o'clock, 3 o'clock, what does that do? It does what I just described. It backs everything else up. So if you are proactively managing your discharge planning process by starting on day one and, hopefully, getting that patient out in a timely manner. Well, that can make all the difference. Getting that second important message, you can give that for up to two days before discharge. So if you're doing things the day before, transportation, meds, the IM, that really will facilitate the time of discharge on the day of discharge. What are your discharge delay reasons? Do you have a discharge lounge? I still see some hospitals with discharge lounges. So when the patient is ready for discharge based on criteria, then they move to another area in the hospital, usually with some kind of employee sitting with them, so that bed can be freed up. And then planning for those post-acute care services or lack thereof and availability thereof. So as we've said, care coordination isn't just about healthcare providers anymore. It includes the patient and the family and the family caregiver. This is a quote from the nurse advocate. They have a, I guess, I don't know if it's a blog, but they send these informational things out pretty regularly. You can ask for them. And in this one, they said, Family caregivers are the unsung heroes of the healthcare system. Studies show that about 44 million Americans provide 37 billion hours of unpaid informal care each year for adult family members and friends with chronic illnesses or conditions that prevent them from handling daily activities, such as bathing, managing medications, or preparing meals on their behalf. So as we've talked about, these are the folks who are helping patients and not getting paid and are considered informal. But you know what? They really shouldn't be informal. They should be part of a healthcare team. So they're caring for those who are ill or frail, and they can be a family caregiver not just at home. They can be a family caregiver while that patient is in the hospital or in rehab or even if that patient goes to a long-term nursing home because they may be speaking on that patient's behalf. So you can think of them as a family caregiver if they're taking care of someone who has a chronic illness or disease, if they're managing meds or talking to doctors and nurses on the patient's behalf, if they're helping to bathe or dress someone who is frail or disabled or doing household chores, making meals, paying bills. You know, even if you go into a relative's home and do the bills for them, maybe they can't see so well. You're a family caregiver. So you can be doing a whole lot. You can be doing one thing, but you are part of that patient's care team. So we have to work together with our family caregivers, and I think I may have mentioned that CMS is talking more and more. If you look at how many times now they're mentioning family caregivers in their dialogues that they send out, you can start to see that they're finding that they have to focus on this particular issue a lot more. So we, as health care professionals, must work together with our family caregivers. During change, during transitions, as we've talked about, this is particularly important as the rules of the road change when the patient goes from the hospital to home with home care. And you have to communicate with them, and you have to see them as part of the team, not just the person sitting over there in the chair. You want to engage with them. So they need a basic understanding of how things are expected to work when that patient gets home with home care. They should have an opportunity to ask questions. Do you have any guides or materials that would help them? Maybe you've got a pamphlet about home care that would be helpful for them to receive. And then acknowledge them, say, okay, this is what you're doing at home for this patient. Well, you are a family caregiver, so give them that right and that title. They may suddenly fall into this role following a crisis, or they may be watching a patient's slow progression or gradual decline and be, over time, taking a more and more and more active part in that patient's care. And we are finding that folks are having to do a lot more because patients are living longer, and they're living longer with chronic conditions and taking a lot of medication, perhaps. So there's a lot more, and people are staying in their homes longer, too. So that means sometimes they need more help in the home. I'm not a caregiver somebody much, Well, you might be those things, but you're also a caregiver. When they take on the role of caregiver, they can act on the person's rights and authority, their rights and authority regarding that person. They can act on the person's rights and authority regarding that person, I should say. And the person can give them those rights and authority in writing, certainly. The right to get information about their family member's condition, the right to be involved in decision-making about care, and to be an essential partner on the healthcare team, be educated. I think these folks are another tool in our toolbox, in our care coordination toolbox. If we inform them and communicate with them and educate them, they're going to help to keep that patient in the correct next level of care. So I see them as a really important piece of what we do. Okay. So some more things that we do in terms of care coordination, then. We identify avoidable delays or patient flow barriers as they occur. So during patient care rounds or when you're doing your clinical review or doing your discharge planning process, you should be stumbling upon some avoidable delays. When you do, you want to try to correct it. When you can't, then you should escalate the issue to your next up, if you will, the person you report to. That could be a manager or a director. If it's something you can't fix, you don't just ignore it, you run it up the flagpole, as we say, to the next person. So this means it's a very active process, and it's an assertive process. And by that I mean, you know, you see it, you try to fix it right away. So that's where we start to do better with our length of stay, by knowing what the plan is, finding delays, and trying to fix them. And then that can go into a database for ongoing performance improvement. So I know that some of you have case management software where it's very easy to put these in, but a lot of the electronic medical record vendors now also have a place for you to enter avoidable delays. And when you do that, my goodness, what's happening is you're looking at patterns and trends. So an avoidable delay identifies the cause of an expected outcome that has not been achieved within a designated time frame, and then it links that delay to an expected outcome. So for our DVT patient who came in on Friday and didn't get their vascular study until Monday, yes, that impacted on length of stay, but that was also a huge quality of care issue. And I've seen this happen. So we exposed a patient to heparin and potentially had a long-term effect, and that was a huge quality of care issue. I've seen this happen. So we exposed a patient to heparin and potential bleeding when they didn't need that heparin in the first place, and we kept them in the hospital for three extra days. I mean, it's just a loser all the way around. So these are some of the definitions. When you think about a delay, you really do want to think about a process for how you identify it, because this is really the linchpin to, I'm going to say it again, chipping away at your length of stay. So first we have the responsible party. This is your broad category. It could be a person. It could be a department to whom the delay is attributed. We're going to look at examples. What is the reason, the actual reason for the delay? So let's say it's a radiology delay. That would be a departmental delay. What's the reason? Maybe the reason is that one of the MRIs is broken, so it caused a delay. Occurrences. How many times, how many episodes were there? And these are related to patients. And the number of days. Was it one occurrence that added one day? Was it 12 occurrences that added 106 days, depending on the issue, and so forth? So not just occurrences but also days because they can tell you a different story. Now, you can have all different responsible parties when you do this, but I'm going to give you the ones that I think are most helpful. You can always have an other. Systems internal to the hospital, systems external to the hospital, the patient as the responsible party, the family, the provider. Now, providers or any direct care providers, so it could be a staff nurse, it could be a physical therapist, it could be a physician, and pay or delays. So those internal issues related to your hospital, we typically see a lot in radiology, but physical therapy, and that's not because physical therapy is a bad department. We just so often see they're understaffed, particularly on the weekends, and so they pick and choose which patients they can actually get to, and sometimes, you know, that causes gaps in care and certainly can cause an increase in length of stay. External issues related to resource availability in the community, as we've talked about, bed availability, particular resource availability, or even transportation delays. So attributed to the patient in terms of avoidable delays, it could actually be a clinical change or complication, again, maybe outside of our control. Unable to care for self, so maybe we initially thought the patient might be able to go home, and now we know they can't, and so that causes a delay. Difficulty in making decisions or a financial issue. Family decision-making delays, most common. Delays in bringing in needed paperwork, also kind of common when you're trying to get that Medicaid application going. And then, as I mentioned, direct care provider delays, errors of omission, so things that weren't done that should have been done versus commission, things that were done that didn't need to be done. You can look at it both ways. Lack of communication, again, or delays in service. You know, when that staff nurse, and you may be wondering, well, how does a staff nurse affect patient flow? Well, they don't get that patient out of bed when it's been ordered, and they're waiting for, I don't know who, to come do that physical therapy or something. When they're not taking out drains or tubes in a timely fashion, they're not progressing diets in a timely fashion, all of that can cause delays from a staff nurse perspective. Don't forget them. Payer delays or issues of delays attributed to the third-party payer. It could be an authorization delay, a preferred provider delay. They want you to send the patient to this particular skilled nursing facility. However, they don't have a bed, and that's one of my favorite causes of delay. So this is what I call the drill-down process. Now we understand who the responsible party category might be, and then we try to figure out the reason, like with physical therapy. If you have a process where the physiatrist has to see the patient and write an order for physical therapy, that's different from the timeliness of the physical therapist actually doing the work, and that's different from the day when two physical therapists call in sick. So all those differences, some are fixable and some aren't, so that's why teasing them out is important. Number of occurrences, number of hours or days. So it could also be that the delay was a four-hour delay. Maybe it wasn't a whole day, and most of the systems now let you do that, break it down into hours. So I thought I'd just give you some of the delay reasons, sample reasons that I've used over the years that are most common. I'm sure you might find one missing from my list here, but these are hospital-attributed delays, so the responsible party is the hospital. Okay, so then we see. Let's pick a good one. Let's pick a good one. Okay. Then we have to figure out why. So the patient's supposed to go. We call. They say it's delayed. The question now is why is it delayed and how long is it going to be delayed? There's your avoidable delay information, bing, bang, boom. You can do that for CAT scan or CAT lab or any of those things. Okay. So the patient's supposed to go. We call. They say it's delayed. The question now is why is it delayed and how long is it going to be delayed? You can do that for CAT scan or CAT lab or any of these. I'm just looking at my list here. Getting records from another facility. Oh, my God. Well, that could be a delay, right? Patient delays. What I did was up top here in italics, you see financial issues under payer, but that's not necessarily the issue. The issue is the patient. It could be that the patient is uninsured or they're uninsured for post-acute care services, so that's the patient. Or we're trying to get a guardianship or conservatorship, that's the patient. Unless now we fall into a big legal delay, then you start to have to really think some of these through, so it may start off here and wind up being a legal issue. And then other patient issues, incomplete admission assessment or history, refusing discharge, and you can see these. Physically unable to progress, psychologically unable to progress, unable to learn, so forth. And then on the bottom in italics, patient unable to place due to behavioral health issues or psychiatric issues. I'm not sorry, behavioral issues, like wandering or something like that, and psychiatric issues. So again, those go to the patient. And we have the family. I have to tell you, having worked on this stuff for a while, family pops up a lot as one of the big ticket items that sometimes gets overlooked. So I gave you some sample reasons for family issues. And when you start collecting family issues and they start to add days on, those may or may not be correctable. So it's important to know them. Why? Because we can parse out the fixable stuff from the stuff that's outside of our control. So if you're having trouble reaching a family member, they're not bringing in those papers. They're refusing to take the patient home. They are unable to learn how to care for the patient and so on and so forth. And then sometimes we do have delays associated with the payer. Of course, you all know, ambulance approval, approval of post-acute care services, delays or incorrect appeal process, delay in getting managed care approval for something, processing forms from them, delay in getting a transfer approved to another institution, transfer to inpatient psych. There can be delays around any and all of these. And I'm sure many, many more. And then provider. So again, not necessarily just the physician. I think, though, I do have a lot of physician stuff on the samples here. But don't forget your other providers. And then on the bottom in blue, I hope you can read that, I put ED-specific delays because a lot of times I don't see my case managers in the EDs actually collecting avoidable delays in the ED. But you can have a lot of stuff specific to the emergency department. Admission from a physician's office for a test or procedure, an ED admission after a pre-admission denial, an ED admission for an elective procedure, an ED clerical error can happen, incomplete documentation of ED findings and treatments, or the dreaded social admission. Oh, my God, you definitely want to put those into your database. Now, this is an Excel spreadsheet. However, most of the case management software, and I'm hoping also the electronic medical records software, allows you to create some kind of a report on this data that you're entering. So I just wanted to draw your attention to a couple of things and why this data can be so vital. So I was mentioning rehab earlier, upper left here, delays related to physical therapy, delays related to bed availability, delays related to consults. So in this case, we're breaking rehab down. This was bed availability for acute rehab, as I recall. And so you get different answers depending on what question you're asking. And then this is real data. If you go down one, two, three, four down, cath lab, delays related to no weekend hours, and delays related to scheduling and transfers. You see all those days delayed? I mean, look at the total for the year to date, 98. That was only a few months. So 98 days. I was the director when this data was collected. I'm going to blow my own horn for two seconds. I was the director when we collected that data, and a year later, we had another cath lab. What was happening was a lot of the hospitals in our system were transferring their patients to us for caths, and that was appropriate, but we didn't have enough cath labs to do all the procedures. So what happened? Those patients stayed in the hospital, and that data that you're looking at right there supported the need for another cath lab, and we got one because that has to go through the state and all kinds of stuff. So the data can be powerful. It really can. And then you also want to know when your data is related to all days of the week versus weekends, because as I've been talking about today, a lot of your delays are coming on the weekend and in the evening time, or off hours. This is not real numbers. This is just to give you an idea of what it could look like. And a per diem rate of $1,000 is not real. I just used round numbers to make it a little easier. Because sometimes when you tell a story in dollars, it's also really helpful. You can ask your finance department, because they should know what your average cost, or reimbursement, you could do it either way, is per day. What's your average dollars that you, let's say cost per day. So if I have six occurrences of rehab delays, adding up to 12 days with my low balling of $1,000 a day, it comes to $12,000, and it was because of weekend delay. Go down to cath lab, again, $98,000, again, low balling. I actually, you know, wrote up a whole report about this. And you can see here, all this stuff, all these system, hospital system delays, were mainly in this example, scheduling delays. But if I pull out just the weekend stuff, let's see what happens. So stress tests, not available on the weekend. MRI, not available on the weekend. All those weekend transfers coming in and so forth. With our low ball of $1,000, still comes to $82,000. So 46% of the delays we saw on the prior slide happened on the weekend. So you could say half of our delays happen on the weekend. And, you know, senior leadership should have an awareness of that because they may say, okay, maybe we need to add this or that service on the weekend. So your avoidable delay data can be used to identify patient flow improvement opportunities, as I've been saying. They may or may not result in a denial. I mean, you can crosswalk them with denials and see, again, electronically, this should be pretty easy now, and see how many of your avoidable delays actually resulted in reductions in payment. That's another powerful thing. So they will affect your length of stay and your throughput and your patient flow, whatever you want to call it. But that's still an issue. It's a quality-of-care issue, and it is a metric issue. So in terms of your internal system delays, you want to collect that data, look for patterns and trends. If it's PathLab, we'll use that again, you're going to share that information with that department and work with them. So as a director, I would take my avoidable delay data monthly. I don't necessarily recommend monthly, but it's up to you. Or every three months, whatever it might be, and you sit with that director of that department and you talk about the data and you see what you can do about it. And a lot of times, it's helpful to them, too, because they're not completely aware of where the biggest problems might lie. So it can be helpful to both. And it's not, you know, a punitive thing. It's really an opportunity for the departments to work together. So you can do a cost-benefit to extending that service. So we have that vascular lab delay issue. How much is it going to cost to have an on-call person who can come in and do that test? How often does this happen and things like that? And then make the business case. For those external system delays, which oftentimes are going to be outside of your control, you're going to look for patterns and trends. Again, you may not be able to fix it, but you want to understand it because it's impacting on your overall length of stay. But if you have issues with particular agencies or vendors that come up repeatedly, then you want to work with them to improve their performance. Maybe there's issues on your side that you can fix that will help them do a better job. Or just make them aware. You can aggregate your patient delays in similar fashion. And look for patterns and trends. And I would bring that data. Well, it certainly should go to your quality department, but also talk to the appropriate clinical department. If you've got a medical doctor who's doing a disproportionately large number of readmissions, for example, and you've got that data, well, you can bring that to that department. So data shows significant delays on weekends due to MRIs. What is the cost-quality effect of those delays? So how much is it costing us? And what are the quality effects? Because when patients don't get that... I've told this story, maybe not to you guys, but I had a friend of a friend, a friend who said to me, her friend was admitted to the hospital where I was the director of case management. And she had come in on Friday, and now it was Monday morning, and she hadn't had her MRI yet. I went to see her. She had gobbled speech. She was confused. So she had been laying in the bed since Friday for an MRI. Now, this was before stroke protocols and things like that, to be fair. But you can imagine the cost. But you can have similar examples. She waited three days to get that MRI, which meant her treatment plan was delayed for three days. And that could have been a very bad outcome. I was appalled, frankly. So what is the cost-quality effect of these delays? And is the gain that would be achieved by, let's say, increasing MRI hours on the weekends worth the investment? It probably is. For family delays, you can aggregate the data. You may have a performance-improvement opportunity, but the data will help at least to explain the increases in length of stay, maybe for a particular patient. And, you know, we try to work with families. This is why you want to develop a relationship with that family, family members, family caregivers, as early in the stay as possible. Because that relationship that you establish early on is going to help you in the discharge planning process and hopefully reduce on some of those delays. And then for your providers, again, aggregate by reason and practitioner. Go to that appropriate clinical department, your directors, and work with them if there are any opportunities to improve performance. So if you've got a particular nurse who's just not getting the patients out of bed, well, you can go to the nurse manager first. You're not going to go to the CNO, probably. But, you know, somebody's got to bring that to somebody's attention, and everybody doesn't want to rat on each other. And I get it, but if you do it as data and show the impact of that data, that can make a difference. And then, you know, and show the impact of that data, that can make a difference. So for process review purposes, you want to identify the process area of interest, identify the subprocess or steps in that area, determine the internal and external benchmarks for the full process and subprocess, if appropriate. So if you've got an MRI delay, what constitutes an MRI delay? How quickly should an MRI be done in your hospital? Is it 4 hours, 6 hours, 8 hours, 12 hours, 24 hours? You should know what that is. And then work around that accordingly. So, again, tools. You have so many tools in your care coordination toolbox. We just talked a lot about patient flow. Patient flow, one of the big tools that you have. Interdisciplinary walking rounds, bedside rounds, another tool that you have. Long-stay care conferences for those really difficult discharges. For your unfunded or underfunded patients, conferences, meetings, maybe with finance. Patient and family conferences, connecting patients to outpatient services that will help decrease their likelihood of being readmitted. So care coordination has a direct impact on length of stay, which has a direct impact on your Medicare spending for beneficiary also. So there it is in your value metrics opportunity. And as we're winding up today, I just wanted to talk about timeouts for a moment. I alluded to timeouts last week, but I wanted to just give you a little more detail. It's something you all might want to consider doing. And it starts back with the Institute of Medicine, back in 1999, to AIR is Human. Some of you may remember this book, which identified, or I should say article, which identified surgical injuries near misses and deaths to be much worse than anybody actually realized. So in 2003, timeout for procedures was first identified as a national patient safety goal, initially to prevent wrong-sided surgery. Now today, every surgical patient, outpatient or inpatient, they use a timeout for that, which is a really good thing. But now we have something that we call non-procedural timeouts. The Society for Hospital Medicine, in 2011, published an article calling for a call for non-procedural timeouts. And what they said was these are critical conversation tools, innovative communication tools to potentially limit communication failures at critical junctures, and the purpose is to ensure high-quality and safe care. So for us, a non-procedural timeout would be a discharge timeout. You know, when the patient comes into the hospital, everybody's very diligent about completing all the admission paperwork and doing everything necessary for that admission. But when patients leave the hospital, it's a lot more loosey-goosey and there's a lot less attention to detail. And discharge isn't just our responsibility. The entire team has responsibilities when it comes to making sure all the things that need to get done to discharge that patient get done. So in a minute, I'm going to talk about what those are. So the Institute for Healthcare Improvement made some recommendations in this regard. Okay, and I do believe this is really important. And I have visited family members and friends in the hospital. Whiteboards are not being used correctly. I even had a friend recently who was in the hospital. The entire time she was there, which was four days, another patient's information was on that whiteboard. Or there's too much information or it becomes a communication tool between care providers. That's not the intention of those whiteboards. Those whiteboards are there for communication with the patient and family. So for us, the date and time of discharge should be on that whiteboard for that patient and family to see and know about. To orchestrate your discharge for your time out the day before discharge, complete any education, do med rec, notify ancillary services, complete your meds to beds, order transportation. So for me, the big ticket items for us are getting the meds to beds if you can and or getting the prescriptions for the patient, getting transportation ordered, and finishing up on any education, making sure the post-acute services are aware that the patient is going. I mean, that to me, you know, is huge. And we want to get those things done. Now, I see they have notify ancillary services by whiteboard. I don't know that that would be appropriate, but certainly extranet notification or phone calls, however you do it in your hospital. Synchronize your admissions and transfers to discharge schedules. So you want to make sure you have, you know, not everybody coming in at the same time and not everybody going out at the same time. I mean, 7 a.m. just never made any sense to me. Patients should be discharged when they're clinically ready to be discharged regardless of the time or the day. You know, everybody isn't suddenly ready on Friday. It's just silly. So if a patient is clinically ready to go home at 6 p.m., then they should go at 6 p.m. The question becomes, is that a late discharge or is that an early discharge? Because if you're not thinking about discharging people then they're going to stay till the next day. So sending them home in the early evening is actually an early discharge, not a late discharge, if you get what I'm saying. And your care coordination has to align with all of your next level of care providers. So we've talked about most all of these through our webinars. And today, for all sorts of reasons that we've talked about, you have to have good alignment with them. You want to have safe and timely communication handoffs. I so, so recommend that you have some kind of a standardized handoff that can be in writing so that all of the team members are sending the same information and it is all the correct categories that you want to send and then even a verbal handoff as well when necessary. Action items that need to be followed up in the community should be communicated. Maybe a test was completed but not reported in the hospital. So somebody in the community, maybe the primary care provider needs to know that. You want to make sure your patient has an appointment within 7 to 10 days after discharge and that they have a way to get to that appointment and prevention of readmissions in the ED by the ED case manager, maybe intervening and coming up with a different plan. What we see is when we've got better post-acute care coordination, we see a decrease in ED utilization, a decrease in readmissions, a decrease in cost, improvement of quality, and improved patient satisfaction. It seems like more work and maybe it is a little more work, but net-net it will result in better outcomes across the board. So we have to make sure we can't just, you know, refer a patient to a post-acute care provider anymore without giving that patient the complete story about the quality of that provider. I think I mentioned before that the post-acute care facilities and home care agencies and LTACs and so forth have to prove that they're worthy of receiving referrals from us. We should expect high-quality care and outcomes if we have any hospital-owned or system-owned, I should say post-acute care providers. Sorry about that. And we should be aware when the patient is in any of these other networks. You know, if they're in a patient-centered medical home, we really should know that because there's probably a case manager there. There's probably a case manager in an accountable care situation or bundled payment situation. And again, those follow-up phone calls that we talked about last week are important. Again, these can be delegated to an accountable person that we'll talk about next week and then bumped up if necessary. So when the patient says, I didn't fill my prescription, well, that's got to go over to the RN or the social worker to intervene on. Don Berwick, some of you may remember him from the Institute for Healthcare Improvement, said patient-centeredness is a dimension of the patient's own rights. It's proper incorporation into new healthcare designs will involve some radical, unfamiliar, and disruptive shifts in control and power out of the hands of those who give care and into the hands of those who receive it. I really like this because I think if you do put the patient at the center of all of this, that it really, you can't go wrong. But I think that's the way it's got to be in the new healthcare environment that we're in. So best practice, care coordination plus effective communication equals an increase in value. We started with value today. We end with value today. And so some resources today for you. And Lindsey, you're up. All right. Thank you so much, Dr. Sesta. You made it. I always tell you, Lindsey, I could look at these slides a thousand times and still miss a typo or this time I left out an entire word. My goodness, sorry about that. It is so easy to do, that is for sure. We appreciate you always sharing your time and it looks like there is one pending question now in the Q&A. And before I read this one out, if anybody has a question, we have about 10 minutes or so left in our allotted time for today. So don't hesitate to be typing in your question there in the Q&A or even in the chat if you don't see that Q&A option. This question asks, is the second IMM delivery within 48 hours of discharge or two days by actual date? For example, if a second IMM was given on a Monday, what day would you have to give another one if there was a discharge delay and anticipated discharge? Yeah, that's an interesting question. CMS usually counts a day as if the patient is in the bed at midnight. So you can do it that way. So I think in your example, let's see, we would have Monday night, Tuesday night. I would say in your example, yes, you would give another IMM or yes, if there's a delay in discharge or the anticipated discharge date is extended, you absolutely have to give another one. Yes. Unfortunately. Perfect. I don't see any other pending questions, so I will just give you a couple of closing remarks here. If you joined us for the previous sessions in the series, then I hope that you have seen these follow-up emails, but just be aware that you will receive an email tomorrow morning and it will come from educationnoreplyatzoom.us and that email will include a link to the full recording of today's session and a link to the slides that Dr. Sesta presented for us today. I did go ahead and provide that link there for you in the chat now to have as a resource as well. And just remember that the link to the recording will be available for 60 days from today's date. And then we do have that extra security measure in place. So when you click on that Zoom link, you will need to enter your information. That will prompt an email to come to us and then we will approve that recording access request very quickly. But we ask that you give us one business day to grant those approvals. And then again, you'll have full access to the recording for 60 days from today's date. And you do see Dr. Sesta's contact information here on the screen. And we are so thankful that she's willing to answer any follow-up questions that you have. So please don't hesitate to reach out. But you can also reach us at education at gha.org. We'll be happy to help in any way that we can as well. We thank you so much for joining us today for Part 4. And we look forward to having you all back with us for Part 5 to conclude our series next week. Thank you so much, Dr. Sesta. I hope you all have a wonderful afternoon. Thank you, Lindsay. Have a good one. Bye-bye, everybody. Thank you.

care coordination

case management

healthcare

patient safety

quality of care

hospital length of stay

cost management

physician practice patterns

resource availability

avoidable delays

family caregivers

interdisciplinary communication

discharge planning

patient handoffs

healthcare outcomes