Patient Flow Management Is Expanding Far and Wide

It used to be that effective patient flow meant getting patients from Point A to Point B within a hospital as efficiently as possible. Today, for some hospitals, the goal for patient flow is to keep patients from coming into the hospital at all. Risk-based contracting, changes to readmission and other payment rules, along with the strategic importance of improving patient satisfaction, are all driving hospitals to create new, off-site options for care. They are working to facilitate better handoffs and coordination among different providers, and encouraging patients to use new care delivery options outside the hospital walls.

Consider: In 2012, the last year AHA Solutions conducted the Patient Flow Challenges Assessment, only about 9 percent of hospitals were prioritizing the post-discharge stage of patient flow and 1 percent were prioritizing home care. Discharge was the leading priority, and hospitals’ patient flow efforts were focused on hiring hospitalists and investing in real-time locating systems (RTLS) to better manage physical assets.

Today, less than four years later, creating non-hospital care options is a top priority for many health systems, which is leading to a flurry of new wellness programs, population health initiatives and partnerships among hospitals and various outpatient service providers. RTLS investment remains strong, but significant sums are also being spent on telemedicine technology and solutions that incorporate personal devices like the Fitbit and iPhone^® into patient management. Hospitalists are still popular, but hospitals also are hiring scores of case managers to monitor telemedicine systems and provide follow-up phone calls to discharged patients. They are also making more use of advanced practice registered nurses (APRNs) and physician assistants (PAs) to redistribute workloads and improve patient flow within the hospital.

“Patient flow is like a balloon — when you push on one part of it, it bulges somewhere else,” says Dr. David Bordo, chief medical officer and vice president of medical affairs of the northwest region for Presence Health, the largest Catholic health system in Illinois. “Population health and risk assessments of discharged patients will influence patient flow and overall performance, so you can’t manage patient flow in a silo.”

Hospitals are succeeding in shifting patients to alternative care settings, but cite getting visibility and information about care outside the hospital as a consistent challenge. Here are some of the approaches hospitals are taking to manage patient flow and information flow to not only optimize quality of care, but also resource utilization and alignment with changing care and payment models.

Improving Collaboration with Other Providers
Advocate Condell Medical Center in Libertyville, Ill., has focused on care transitions to skilled nursing facilities in its efforts to stem reverse flow, i.e., readmissions. The hospital tries to schedule rehabilitation sessions and other follow-up care for patients before they leave the hospital. It found this improves compliance with post-discharge instructions. The hospital has extensively studied outcome data to identify skilled nursing and other facilities with high success rates and encourages patients to use those facilities.

“We are also lucky to have our own home health care agency. We can look at its data for readmission rates and we also look at readmission data for skilled nursing facilities. That has helped us jointly plan how to improve outcomes by specifically targeting unnecessary utilization,” says Dan Doherty, administrator, professional services at Advocate Condell Medical Center. “The biggest challenge is reducing utilization and preventing admissions when patients have a choice to use facilities that do not have a population health mindset.”

Advocate also reviews a lot of outcome data from its population health program and tries to work with providers with results that are outside the norms. “Having patient-specific information and being able to tie that patient back to a physician, skilled nursing facility, home health agency or hospital is very valuable for improving outcomes,” Doherty says.

Getting the data from other providers to make care plans and better manage patient flow has traditionally been a challenge. Payment reform is removing some of the obstacles, according to Bordo: “As we move to ACOs and risk-based contracting, and as more contracts are capitated, it is much easier for me to reach out to nursing homes and rehabilitation facilities in my network to see what is happening. It’s all changing, and getting data is easier, especially for bundled payment patients.”

Having more data does not require analytics or new technology to make it useful. Bordo’s organization uses the visibility to data it gets from other providers to improve its anticipated patient volume, then uses proven, low-tech methods to improve patient flow. It introduced multidisciplinary rounding, holds daily safety huddles, tracks progress to the care plan for each patient and posts daily bed goals and progress status on boards for all relevant personnel to see. “We’ve eliminated the ‘4 o’clock shock’ that used to occur when we needed 10 PACU beds and would find out at 4 o’clock that we’d only have one available,” says Bordo.

Staffing, Role and Process Changes
Staffing changes that hospitals make to expand outpatient engagement and mitigate physician shortages can also improve patient flow. “We are seeing advanced practitioners (advanced practice registered nurses and physician assistants) being given more privileges, which then helps throughput,” says Trish Anen, vice president of clinical services for the Metropolitan Chicago Healthcare Council (MCHC), which co-founded and sponsors the Center for Advancing Provider Practices (CAP2), a group that develops resources to help integrate APRNs and PAs within health care delivery teams.

CAP2 data shows advanced practitioners have approximately 66 percent of the core privileges typically granted to physicians, according to Anen. They are being used in 45 clinical practice settings and are now included in approximately 68 percent of hospitalist teams and 50 percent of intensivist teams, according to the latest CAP2 data.

Case managers are also playing a larger role in care delivery, and by extension, patient flow. Again, avoiding readmissions is a big driver. The case manager’s primary responsibility is to make follow-up calls to discharged patients to help them follow their after-care instructions.

Candace Hanrahan recently hired the first nurse case manager for Prince George’s Hospital Center in Cheverly, Md., where she is vice president and chief nursing officer. She was encouraged by the strong pool of candidates that were attracted to the position. “This kind of population health role is very exciting and has a lot of possibilities. The position drew a lot of interest, especially among seasoned nurses,” says Hanrahan.

Case managers are especially effective when used to support remote patient monitoring and other forms of telemedicine. A single nurse case manager can monitor 50 to 300 outpatients per day depending on their acuity, according to Jonathan Leviss, chief medical officer at AMC Health, which has received the American Hospital Association’s exclusive endorsement for remote patient monitoring and patient engagement solutions.

Telemedicine: the Key to Improving Flow and Alignment?
Remote monitoring solutions can replace the need for patients to return to the hospital for follow-up tests and exams and can be very valuable for preventing readmissions by providing an early warning for developing problems. As such, remote monitoring can be viewed as an enabling technology for new care models that focus on collaborating with other providers and reducing preventable hospitalizations.

“We’ve learned we can get better outcomes and lower costs when we engage patients outside the hospital,” says Leviss. “Health systems can actually flourish if they pursue this and don’t do business as usual.”

As new care paths and payment models continue to evolve, organizations will need to review and adjust their approaches to patient flow. Patient flow is not as straightforward as it used to be, but hospitals are successfully navigating it with the help of new technology tools, staff roles and processes.