Background: In the throughput arena, one of the most challenging groups of hospitalized patients is the long length of stay (LLOS) patients. Although representing a minority of inpatients, this LLOS population contributes to the majority of excess days. At our urban tertiary academic institution, a LLOS is defined as greater than 15 excess days. In 2017, 6% of our inpatients were deemed LLOS and these patients averaged 16.3 excess days per case. On review of these patients, the most common barriers to discharge include lack of insurance, complex medical conditions and delayed placement at rehabilitation/skilled nursing facilities. Prior to 2018, our LLOS committee was poorly attended and largely ineffective.
Purpose: Our primary goal was to create an engaged and effective early intervention committee (EIC) that identified LLOS patients early in their hospitalization. With prompt identification and intervention we anticipated a decrease in the percentage of our patients that had > 15 excess days per case.
Description: In 2018 we revamped our multidisciplinary EIC and now meet on a weekly basis to identify patients who are at or approaching the LLOS threshold. We discuss common issues surrounding these cases and creatively problem-solve barriers. Our EIC consists of physicians (hospitalists, palliative care, chief medical director), case management, psychology, social work, ethics, financial counseling, home care, and sub-acute rehabilitation/SNF representatives. Case management and social work review all cases prior to the meeting and report the clinical and non-clinical needs. We conduct real time discussions with team members regarding the medical plan of care and any barriers to discharge planning. Some examples of common barriers and actions taken include: 1) Uninsured patients: financial counseling services are provided from day 1 of admission. 2) Delayed placement at sub-acute rehabilitation/skilled nursing facility: our institution partnered with more in and out of network community resources and established key contacts at insurance companies for immediate escalation. 3) Complex medical conditions: our institution also increased partnerships with local hemodialysis, wound care facilities and ventilator companies to broaden options for our patients. The medical complexity of our patient population has increased in the past year and the percentage of our LLOS cases has increased from 5.9% to 6.2%. However, with the above interventions, the number of excess days per case in the >15 excess day cases has decreased from 16.3 days to 15.8 days.
Conclusions: This highly functional EIC provides timely and appropriate services for a small yet challenging subset of patients. The efforts of this committee along with active participation of hospital leadership have led to improvements in the throughput of this challenging population.