The Complex Case Discharge Delay Problem

The complex case discharge delay problem © 2021 Healthcare Association of New York State, Inc. THE COMPLEX CASE DISCHARGE DELAY PROBLEM Acknowledgments HANYS thanks members of its complex case discharge delays workgroup for their guidance in developing this white paper. Kelly Degonza, RN Sheryl Mersten, RN, BSN CONTINUUM OF CARE SPECIALIST, DIRECTOR, CASE MANAGEMENT AND SOCIAL WORK, ALBANY MEDICAL CENTER JAMAICA HOSPITAL MEDICAL CENTER Deborah House, LMSW, CCM, ACHP-SW, CCI Kenneth Thayer, RN, BSN DIRECTOR, SOCIAL SERVICES AND CARE MANAGEMENT, ASSOCIATE VICE PRESIDENT, PATIENT CARE, ST. PETER’S HEALTH PARTNERS THE UNIVERSITY OF VERMONT HEALTH NETWORK - CHAMPLAIN VALLEY PHYSICIANS HOSPITAL Amanda Laprime, PhD, BCBA-D ASSISTANT PROFESSOR, PEDIATRICS, TRANSITIONAL MEDICINE, Mitchel F. Todd, MSW, LMSW DIVISION OF NEURODEVELOPMENTAL AND BEHAVIORAL PEDIATRICS, DIRECTOR, CASE MANAGEMENT AND UTILIZATION REVIEW, UNIVERSITY OF ROCHESTER MEDICAL CENTER ALBANY MEDICAL CENTER Lorna Manning, MHM, MBA, ACM-RN Alan Wilmarth, CASAC ASSISTANT VICE PRESIDENT, INTEGRATED CASE ADMINISTRATIVE DIRECTOR, BEHAVIORAL HEALTH, MANAGEMENT AND POPULATION HEALTH, UNITED HEALTH SERVICES HOSPITALS, INC. ST. JOHN'S EPISCOPAL HOSPITAL Questions? Sarah DuVall, MPH, CPHQ, Director, Behavioral Health [email protected] Victoria Aufiero, Esq., Senior Director, Insurance, Managed Care and Behavioral Health [email protected] © 2021 Healthcare Association of New York State, Inc. THE COMPLEX CASE DISCHARGE DELAY PROBLEM Table of contents 1 Executive summary 3 Background 6 Gaps in the care continuum 7 A system design flaw 11 Attempts to address the challenge 13 Next steps 14 Real examples of common scenarios 17 References © 2021 Healthcare Association of New York State, Inc. 3 THE COMPLEX CASE DISCHARGE DELAY PROBLEM Our system of care has a design flaw — it is primarily designed for people with a clear path, for those who do not have complex care needs upon discharge. © 2021 Healthcare Association of New York State, Inc. 1 THE COMPLEX CASE DISCHARGE DELAY PROBLEM Executive summary A 12-year-old girl was admitted to a hospital in New York state with U.S. and the world.1, 2 These delays happen for many reasons, symptoms due to a traumatic brain injury and bipolar disorder. She but are most commonly attributed to difficulty finding safe was clinically stabilized and ready for discharge two weeks later, post-discharge care and lengthy administrative or legal but when no safe discharge options could be found, she became processes. Individuals experiencing behavioral health, intellectual stuck in an acute locked psychiatric setting for eight months. or developmental disabilities and/or co-occurring conditions are Pleading for a placement, her hospital social worker wrote: most profoundly impacted. Once a person enters through emergency room doors, hospitals “She cries hysterically daily, begging for a discharge, and claiming become responsible for their safe care and discharge.3-5 As a she is forgotten in a psych ward ... she is tenacious, funny, loving, result, people are often brought to the emergency department connects well with adults, has spirituality, a great sense of humor, as a last resort — when no other options for care can be found. and dreams for her future.” The unintended consequence is a system where hospitals are Hundreds of New Yorkers experience a similar fate each year: left bridging gaps between health and social care; serving as months-long hospital stays. Thousands more experience some a long-term destination rather than as a way station for those kind of non-medically necessary discharge delay. Regardless of who, once their acute care needs are met, are better served in a whether the delay is days, weeks or years long, there are risks non-hospital setting. and harm to patients who could otherwise be served at home, in the community or other less expensive care setting — without Our system of care has a design flaw — it is primarily designed disrupting access to care for others. The time to confront this for people with a clear path, for those who do not have complex persistent challenge is long overdue. This paper provides a high- care needs upon discharge. There may not always be a perfect level examination of the complex case discharge delay problem in discharge setting for complex case patients. However, there is New York state and outlines a way forward. a shared responsibility to acknowledge this problem and find the perhaps imperfect but best possible solution. What we are Complex case discharge delays, also known as bed blocking or doing now is a disservice to our communities and people who bed delays, are a longstanding, growing challenge throughout the “live” in a hospital. HANYS seeks to convene stakeholders, and offer expertise in setting policy while strengthening relationships and establishing best practices across the field to achieve better patient outcomes. The following actions will help patients and hospitals in the short term, and create the foundation for long-term solutions: • build and maintain stakeholder dialogue to make • develop consistent behavioral rules and practices for New York best in class at solving complex dis- county agencies, community-based providers and/or charge cases; other stakeholders; • establish a senior level, multi-agency response • form complex case discharge response teams in every team for cases that should be escalated to com- hospital and health system; missioner level direction, with provider input; • educate hospital staff about the full range of resources • identify mechanisms to understand the extent and available; and scope of this issue through a multi-system analysis; • identify clinical and administrative practice and process • advocate for changes to regulations or advancement improvement strategies. of legislation to remove barriers and create care models to address gaps in the care continuum; © 2021 Healthcare Association of New York State, Inc. 2 THE COMPLEX CASE DISCHARGE DELAY PROBLEM There is a shared responsibility to acknowledge this problem and find the perhaps imperfect but best possible solution. © 2021 Healthcare Association of New York State, Inc. 3 THE COMPLEX CASE DISCHARGE DELAY PROBLEM Background Our healthcare delivery system has undergone significant transformation to reduce unnecessary hospitalization; Imagine the unconscionable payers have developed payment models to incentivize experiences suffered by patients providers; New York state has allocated billions of dollars to initiatives such as the Delivery System Reform Incentive who live in limbo for months to Program;6 and hospitals have formed partnerships, invested in population health and adopted tools like Lean years in the hospital environment. and high reliability.7-9 Despite these investments, patients They lose their autonomy, become with complex care needs continue to become stuck in EDs and inpatient units for weeks, months or years, with socially isolated and lack access catastrophic ramifications.10, 11 to the intellectual and physical In this paper, HANYS describes the unintended consequences activity necessary to thrive. of a system that does not “see” complex case patients, based on the experiences of hospitals and patients. Unintended consequences When patients become stuck in hospitals they are deprived Patients of what they need to progress and often deteriorate. They often need more advanced care upon discharge than when A lack of coordinated care options has created an environ- they arrived.23 Complex case patients with behavioral health ment where complex case patients needlessly languish in disorders and/or intellectual and developmental disabilities 12, 13 EDs and hospital beds. Evidence shows that unnec- are especially vulnerable because their conditions are also essary hospital stays can lead to an irreversible decline often poorly understood. in functional status and negatively impact psychological well-being, especially for older adults and children.14 - 18 Hospitals have adapted to best meet the needs of Prolonged hospitalizations worsen these impacts in immea- patients, but they are expertly engineered to provide surable ways.19 Imagine the unconscionable experiences acute care in the short-term, and are not an acceptable suffered by patients who live in limbo in the hospital envi- place to live. ronment. They lose their autonomy, become socially isolated and lack access to the intellectual and physical activity Care delivery necessary to thrive.20 - 22 Most families are left in turmoil; watching helplessly and wrestling with care options that Bed shortages undermine their own well-being. Discharge delays limit access to beds for others who need These repercussions are most profound for individuals who hospital care, a critical problem highlighted most recently are already struggling with disabilities and/or behavioral during the COVID-19 pandemic.24, 25 Patients who may oth- health disorders. Advances in science and investment into erwise receive inpatient care in their local community may community programs have allowed individuals who were need to be diverted elsewhere. Further, bed shortages lead previously institutionalized to achieve higher levels of inde- to ED boarding, a situation where patients are admitted pendence than ever before. Access to a stable environment, to a hospital, but remain in the ED, often for days, until regular participation in therapy and the freedom to partic- beds become available.26 ED boarding contributes to ED ipate in social or physical activity

Load more