Care Continuum Management team expands pilot program to improve the discharge process hospital wide

Each year, as part of Brigham and Women’s Faulkner Hospital’s ongoing commitment to providing the safest, highest quality care to our patients, departments across the hospital are charged with developing and implementing their own Quality Assurance Process Improvement (QAPI) plan. This year, the Care Continuum Management team is focused on expanding an existing pilot program hospital wide in order to improve the discharge process.

“Reducing length of stay is a hospital-wide goal,” explains Director of Care Continuum Management James Grafton, MSN, MHA, RN, CCM. “One way my team can help us reach that goal is by ensuring discharge plans—whether that’s finding a bed in a long-term care facility, setting a patient up with a home health aid or simply determining that it’s safe for the patient to return home—are in place for each patient as soon as possible.”

Grafton began by piloting the Early Screen for Discharge Planning (ESDP) Tool developed by Holland, Knafl and Bowles on 7 North, a medical/surgical inpatient unit. Using the tool, members of the Care Continuum Management team pull information from the patient’s electronic medical to evaluate them based on four variables: age, disability, living situation prior to hospitalization and self-reported walking limitation. If a patient scores higher than 10, a member of the Care Continuum Management team will do a full assessment of the patients. If the patient scores less than 10, no further assessment is needed, meaning the patient is cleared for discharge by Care Continuum Management.

“We’re basically triaging patients electronically with the goal of freeing up our Care Continuum Management team members’ time to work with those patients who require our services,” says Grafton. “Of course, if any member of the care team feels a patient scoring less than 10 needs to be seen by Care Continuum Management, or the patient themself expresses concern, we will proceed with a full assessment.”

The pilot showed that the wins are two-fold—for patients scoring less than 10, there is one less hurdle for them to get over before going home, and for patients who need more complex discharge planning, members of the Care Continuum Management team have more bandwidth to work on their cases and, in theory, can set them up with after care faster.

Having seen positive results on 7 North, the team is now moving out of the pilot phase and implementing their new process on all the inpatient units. “We’ll be tracking the data over the coming months, but I am fully confident our new process will improve our length of stay numbers and, most importantly, help our team provide appropriate services to those who need it most in a timely fashion.”

Published 8/16/22