Proactive Length of Stay Management

Sue Erwin DNP, RN, MHA, ACM-RN, CMAC 

Hospitals employ many interventions to impact Length of Stay (LOS) since we all face increasing financial challenges and an increased LOS where care and services are being provided but there is no financial reimbursement paid beyond the original Diagnosis Related Group (DRG). 

One tool used by hospitals is to conduct a long LOS meeting weekly to evaluate those inpatients who have been in the hospital for seven days or more. I maintain that evaluating these patients at seven days is too late to obviate barriers to discharge and make a meaningful impact on hospital LOS. 
At my organization we are privileged to have a robust internal Physician Advisor (PA) program which is foundational for meaningful change.   At Wake Forest Baptist Health we hold a LOS meeting every Tuesday and Thursday named the “Quality Collaborative”. When we initially started this meeting to address LOS and barriers to discharge, we reviewed all inpatients with a length of stay of eight days or longer.  The meeting would take about 2 hours.  We have progressed to reviewing all patients in the hospital who have been an inpatient for three days or more and this takes 2.5 hours to complete.  By intervening earlier in the stay we are able to more effectively manage barriers to discharge or secure faster placement for post-acute needs.   
This meeting is led by our Physician Advisor and Manager of Care Coordination. Prior to Covid-19 we held this meeting in person and each case manager and social worker would attend at a specified time and give report on the medical reason that the patient remains in the hospital and what the barriers to discharge are in a rapid-fire fashion. Since Covid, we have been utilizing Webex to accomplish this meeting to preserve social distancing.   
In addition to reviewing inpatients, the Physician Adviser reviews the Observation list of patients daily seven days a week with the Utilization Review Nurse to make determinations regarding discharges or conversions to inpatient that are appropriate. 
Our organization has established rich relationships with the skilled nursing facilities, assisted living facilities and behavioral health providers and often a bed can be located in one day. We meet with our post-acute providers on a quarterly basis to foster those relationships and communicate our expectations.   
In addition to reducing the Average LOS at an 885 bed Academic Medical Center by almost one full day, this meeting has served to educate our case managers and social workers on how to eradicate barriers to discharge, and increase knowledge of when it is appropriate to use Hospital Issued Notices of Noncoverage (HINNs).  We believe that our case managers are the “nucleus of care” and serve to integrate the various team members toward effectuating a coordinated and comprehensive discharge plan. 
In conclusion there are many other innovative programs in place including the High Risk Initiative, active multi-disciplinary rounds and Letters of Guarantee (LOG) for our skilled nursing facilities to empower our team to reduce LOS. I will share more on those initiatives in future ACPA articles. 
Sue Erwin DNP, RN, MHA, ACM-RN, CMAC is Associate Vice President Care Coordination, Wake Forest Baptist Health in Winston Salem, NC.