Rounding and Complex Patients
As case managers, we have all heard the question, “Why is that patient still here?” The question may have come from the attending physician or maybe from senior leadership, but the question is always directed to the case manager! While these complex cases can feel overwhelming, there are strategies to be used that increase the efficiency of discharging these time-consuming patients. The use of daily interdisciplinary rounds and establishing processes for further review of complex cases develops pathways for difficult cases towards a transition of care plan while expediting difficult discharge barriers.
Daily Rounds and Progression of Care
Daily interdisciplinary rounds should occur at the same time and location every day with attendance by the case manager, floor nurse or supervisor who has rounded on all patients on the unit, utilization review, physical therapy and physician advisor or attending, dependent on your model and availability. If you move the meeting time or location, you may lose attendees. Keep it consistent Monday through Friday so that they become part of the team's daily routine. Weekend rounds are not usually possible as we drop to a skeleton crew and put out fires all day! Additional attendees can include pharmacy, palliative and dietary care on specialty units such as the ICU. The focus of daily rounds is a progression of care for patients who are expected to discharge today or tomorrow. A few questions that need to be answered: What are the barriers? From a medical perspective, what needs to occur for the patients to discharge? What does the CM need to do today for the patients to be ready on their discharge date? These rounds need to move quickly through, likely 1-2 minutes per patient and typically occur on or near the nursing unit.
Complex cases that are length of stay outliers occur related to medical and social situations and should be discussed during a weekly meeting. Locations of this meeting can be rounds to the units, case manager offices or in a meeting room. Discussions include patients who may be without a payer, are from another country, have guardianship or ethical issues, social or financial barriers that affect discharge and other outlier complexities that are individual to each patient. Regardless of which of these apply, these patients are typically very time-consuming and can become outlier patients who affect bed capacity and burnout of the hospital staff who care for them. They may also use an inappropriate amount of hospital resources during a time when healthcare is already incredibly strained and exhausted. With the current shortage of bedside nurses, the importance of this population of patients can affect daily operations in hospitals with a shortage of beds and staffing.
Weekly complex case review rounds can occur as physical rounding to the units or case manager offices or as a meeting in a designated space. Regardless of how your facility decides to process, this will meet the Medicare Conditions of Participation 482.30. The condition requires hospitals to conduct a review of duration of stays and professional services and for the meeting minutes related to these complex meetings. These meeting minutes need to be elevated to the Utilization Management Committee (UMC) for review. As stated above, the complex rounds meeting should occur once a week and include the case manager, social worker, case manager director and a Physician Advisor or Chief Medical Officer (CMO) in attendance. Additional stakeholders can include finance, palliative care, admissions and anyone who your organization feels adds value to the meeting. This is your meeting; make it work for your organization!
The length of stay of the patients discussed should also be determined by your team. Don’t decide on a 7-day length of stay review for this meeting and then discuss patients who are appropriate in the ICU at day 7. You may decide on a LOS of 7 days for med/ surg and 10 days for ICU. Find a starting place and adjust as needed to address those patients who are truly outliers. Case managers should also be encouraged to bring patients, even if it is the day they are admitted, that are obviously going to be a discharge challenge. Seasoned case managers will recognize these patients during the initial assessment. Talk about them early and start working on a plan as a team if you already know that they are likely to become an outlier.
Daily rounds create a forum to discuss those patients who should discharge today or tomorrow and ensure we have their needs addressed. Weekly complex discharge rounds give a place for the more complex patients to be discussed in more detail related to their individual needs. The use and combination of these two meetings will improve communication between the caregivers and stakeholders invested in the cost of care, progression of care and improved outcomes of the patients. Discharging these patients is a team effort and should involve senior leadership when required. Next time, they will not ask you why the patient is still admitted. Instead, they will be involved in the process and celebrate with you when that difficult patient has left! Complex patients may continue to increase and we, as case managers, will continue to work diligently to ensure they move safely and efficiently through the progression of care.
BIO: Marie Stinebuck MBA, MSN, ACM
Marie is the Chief Operating Officer of Phoenix Medical Management, Inc., the leading case management firm. Marie has practiced as a nurse for the past 25 years with 17 years in the field of case management. Marie has served in several roles in Senior Leadership roles in Case Management. Marie has authored numerous articles, is a weekly contributor on Finally Friday, and is a Board Member for the Arizona ACMA.
For more on how to move patients safely and efficiently through the progression of care, explore the online course "Improving Transitions of Care: What’s Working and What Have We Learned?" at https://www.pathlms.com/cmsa/courses/36380 (FREE to members!)