Article originally published in Healthcare IT Today
By Andy Oram

Anyone who has had the misfortune to land in the hospital, or care for a relative in one, knows the following frustrating experience: The doctor comes during morning rounds and says the patient is good to go…and hours later, you’re still waiting for the paperwork to get done.

I decided to unpack this experience. During conversations with about 20 experts, I learned about the complex plans that go into the simple act of getting a patient out of the hospital. This article discusses some organizational and workflow measures that hospitals are taking to shorten discharge times, saving money along the way. A subsequent article will chime in with some technologies that help.

Factors Delaying Discharges

Where to begin? So many hospital activities were cited by respondents to my question that I can hope at best to summarize the most salient of them. I’ll run through the observations quickly in order to get to solutions, which boil down to “Think about what you’re doing.”

First, according to Donna Pritchard and Joy Avery of CipherHealth, a company with a communications platform for healthcare, discharge may take time because a lot of important procedures lie between the doctor’s proclamation and the actual discharge. The patient might need some physical therapy, more tests to prove they are free of disease, a dose of antibiotics, etc. Lisa Weber, Director, Healthcare Industry Practice at UiPath—a company that automates elements of the workflow in healthcare and other industries—offers a partial list of people who participate in discharging the patient: the patient themselves, patient caregivers, charge nurse, doctor, therapists, and care manager.

Complexities multiply as we look at external conditions that have to be met. Is the patient’s caretaker at work at the time of discharge? It might take hours for a wife or daughter to arrive to take the patient home. Does the patient even have a caretaker? (Many do not.) And does the patient even have a home? A patient might need complicated help such as in-home care, a wheelchair, or oxygen.

The doctor who ordered the discharge has to sign off when everything necessary has been done, and that doctor might be doing a four-hour surgery or be otherwise busy at the moment.

Patients lacking external support are more common than one might think. As reported in the New York Times, alarming breakdowns in Britain’s social services are mucking up timely discharges there. Strikes among nurses and ambulance workers are curtailing services too, of course. But most of the delays in discharges are caused by a lack of social services—in short, the discharged patient has nowhere else to go.

Delays in discharges, in turn, are backing up other services. They are cascading into delays in emergency rooms, and reaching further from there to cause delays in the dispatch of ambulances to handle new emergencies. Dr. Pallabi Sanyal-Dey, director of client services for inpatient beds at LeanTaaS, points out that a super-full hospital has fewer choices about where to place new patients.

Dr. Jason Cohen, Senior Director of Clinical Solutions at Qventus, a healthcare automation company that uses AI to promote patient flow, talked about the increasing complexity of in-patient stays. Over the past decade, patients have tended to be sicker than they were in the past. The hospital has to juggle not only clinical needs, hospital operations, and the ever-stricter rules of payers, but social determinants of health as well.

The role of the care manager was explained by Cohen as well as by Matt Hollingsworth, CEO of Carta Healthcare, which carries out predictive analytics based on healthcare data from registries. A care manager is assigned to each patient to make sure treatment progresses. Cohen says that doctors depend heavily on care managers to ensure a safe, timely discharge.

But care managers, like other hospital staff, are currently in short supply. Many retired during the COVID-19 crisis, and remaining staff tend to be less experienced. At the same time, the complexities of their job have increased dramatically over the last ten years as the care managers have become responsible for coordinating the social, clinical, operational, and financial aspects of a patient’s stay in an increasingly complicated payor environment.

Cohen said that a case manager nowadays could often be following 30 patients at a time. So a patient could be waiting for discharge because of back-ups in case management–just like so many shortages that degrade service throughout the economy nowadays.

If the patient is supposed to be discharged to a skilled nursing facility, it might take hours for a care manager to research which facilities meet the patients’ needs, contact the facilities to see whether they have a bed, and fax over the necessary documentation (because the nursing facilities are hardly ever tied in to the hospital’s electronic records). According to Dr. Darin Vercillo, CMO and co-founder of ABOUT, a company that orchestrates access to all networks of care throughout the patient journey, case managers often waste time checking facilities that are inappropriate or even defunct.

Many patients have unique needs; some, for instance, need access to dialysis and therefore a facility that offers that service. The facilities also have their own requirements, such as a negative COVID-19 test or a physical therapy evaluation, before transferring the patient. Vercillo says that hospitals used to have the luxury of transferring a patient to a facility the day after a decision was made to do so. Now the facilities need more advance notice.

There may be other factors that are harder to uncover and fix, because the incentives of individual staff people might not match the desires of the patient and payer. If the hospital is being paid by the length of stay, they will obviously lack an incentive to let the patient go early. Even an individual nurse might keep a patient in a bed so that the staff can catch up on lagging tasks before they have to deal with a new patient. According to Vercillo, treatment is harmed more by the shortage of nurses than a shortage of hospital beds.

Workflow Changes That Can Help

My respondents unanimously said that improving discharge times requires a coordinated approach that looks at hospital workflows holistically. Hospitals should iron out differences in workflow as much as possible.

The respondents also highlighted the importance of starting discharge planning early in the stay. As Cynthia Davis, clinical transformation executive at the advisory firm Healthlink Advisors, says, “Start at the first hour to make a safe transition to the next place of care.”

One Wolters Kluwer paper (suggested to me by Dr. Geoffrey Rutledge, Chief Medical Officer and co-founder of the telehealth provider HealthTap), which summarized a research project on discharge planning, identified “15 separate critical discharge elements” and emphasized the importance of coordination and shared planning.

If the hospital is planning ahead and is conscious of its own workflows, staff can anticipate external needs. They can do the necessary research on skilled nursing facilities in advance, and give a caretaker or ambulance company advance notice of when the patient will be discharged. Vercillo points out that the patient and caretakers need time to decide on a nursing facility, if several are available.

Luigi Mantellassi, CEO of Planisy, a company that connects elements of the workplace for better coordination, said that the COVID-19 crisis, which strained hospitals and their staff in so many traumatic ways, also pushed them to reevaluate and streamline workplace systems to make them more flexible to handle unforeseen problems.

Hollingsworth pointed to a study named Target-Based Care: An Intervention to Reduce Variation in Postoperative Length of Stay, by Andrew Y Shin et al., finding that good planning can cause a 36% reduction in the total length of stay.

Conditional discharges speed up the process if done right. In this process, the doctor signs a discharge order that cites conditions to be fulfilled: For instance, the patient must be tested for evidence of risk factors that might require keeping the patient. When all the conditions are fulfilled, the doctor is contacted one last time to give a thumbs-up to discharge.

Vercillo suggests a focused approach: “going deep” into a particular area. Each solution that the hospital finds might improve discharge times for only 10 or 20 percent of its patients, but that can still have a significant impact on overall efficiency. Similarly, Gerry Miller, Founder and CEO of Cloudticity, a cloud service for healthcare, suggests looking for many small fixes instead of an overarching solution.

Vercillo also wants more attention to post-discharge care. For instance, you shouldn’t just tell a patient or caretaker to schedule a follow-up visit, because many are too overwhelmed with their immediate health needs to handle the logistics. “We’re expecting heroic capabilities from our patients,” he says. So the hospital should make sure that the necessary follow-up visit is scheduled. The hospital should also send the patient home with at least a few days of the medication they need. Cindy Gaines, chief clinical transformation officer at Lumeon, a care orchestration tech company, suggests that delivering the medications needed by patients directly to their rooms before discharge makes the transition to the home smoother.

How can IT help? I’ll examine options in a follow-up article.