ONE BIG OBSTACLE that ties up beds and helps keep patients stuck in the ED: delays in discharges to post-acute facilities. Lakshmi Swaminathan, MD, MHSA, serves as division head for hospital medicine for Trinity Health IHA Medical Group, overseeing a team of 190 hospitalists and advanced practice providers. The group cares for as many as 700 patients hospitalized daily across five Trinity hospitals in southeast Michigan.
Dr. Swaminathan shared these 2022 data from the American Hospital Association: Between 2019 and 2022, the average hospital length of stay increased more than 19%. That jump was greatest for patients being discharged to post-acute facilities. While the CMI-adjusted average length of stay of patients being discharged home rose 12.6% over that period, the increase for patients being discharged to SNFs was 20.2%.
Within Trinity Health Michigan, which is based in Livonia, Mich., Dr. Swaminathan said that delays for patients going to SNFs now total 2.9 excess days per patient.
“In our health system, discharge delays for patients going to SNFs account for more than 60% of our excess days.”
Lakshmi Swaminathan, MD, MHSA
Trinity Health Michigan
“In our health system,” she pointed out, “discharge delays for patients going to SNFs account for more than 60% of our excess days.” A deep dive into those data found that the time between asking insurers to authorize a SNF stay and being notified of the payer’s decision contributed to many of these delays.
To reduce such delays, Trinity Health Michigan worked closely with its post-acute care network to craft transition collaboration agreements. The agreements, she explained, allow her team to expedite discharges when the delays are purely administrative—pending insurance authorization—and patients are medically ready for discharge.
“As part of our agreements, SNFs accept higher risk with these patients,” she noted. In return, should an insurer ultimately deny authorization, the hospital agrees to pay 50% of a post-acute facility’s per diem rate for up to two days. One stipulation: That rate can’t exceed Medicare reimbursement.
As to how often such denials occur, a 2024 pilot program testing these agreements saw 50 patients discharged from Trinity Health hospitals to seven different participating post-acute facilities. The average savings in hospital LOS per patient was 1.7 days—and fewer than 5% of pending payer authorizations at discharge were denied.
The program is now being expanded across the health system, and the agreements are being refined. Because of the financial risks, the program involves significant coordination between hospital case managers and SNF admissions coordinators to identify the right patients and to facilitate the referral and discharge process.
“Working through this,” Dr. Swaminathan said, “required us to think beyond our hospital and across the continuum of care to address throughput and ED boarding issues.”
Better care for boarded patients
Trinity Health Michigan has also put innovations in place to deliver safer, more consistent care to patients while they are being boarded in the ED.
According to new care protocols, hospitalists now initiate care to those patients within four hours of the decision to admit them. To do so, “we had to adjust our hospitalist staffing ratios in terms of admitters and cross-cover and rapid-response teams to include ED boarders,” Dr. Swaminathan said.
The health system also created the position of a dedicated nurse navigator to support ED staff when caring for admitted patients being boarded. These staff members assist ED nurses with pending orders and admission assessments. They also make sure boarded patients aren’t deteriorating in the ED.
The role is filled in two different ways, depending on the hospital. In some, the dedicated nurse navigator is onsite; in others, it is a virtual nurse navigator who monitors all admissions waiting in the ED.
Other interventions to provide more timely care to boarded admissions include optimizing an automated medication dispensing cabinet in the ED that includes antibiotics, heparin and DOACs, and renally-eliminated medications.
Pharmacy techs evaluate the medication histories of ED-boarded admissions and update admission medication lists. Case managers round on these patients every six hours to initiate transfer referrals, if needed, and to keep patients and families up to date. Case managers also start getting together lists of possible SNFs, and they assess boarded admissions for social determinants of health.
One final intervention: Every patient being boarded in the ED for more than four hours receives a comfort kit.
“We sometimes don’t realize how much of an impact little things like a toothbrush or ear plugs can have on patient experience,” said Dr. Swaminathan. Developed in coordination with the patient experience committee and patient family advisors, the comfort-kit bag that patients receive also includes toothpaste, an eye mask, body lotion, body wipes, no-slip socks, a comb, lip balm and a notebook and pen.
“We know the ED isn’t the ideal place where patients want to be,” Dr. Swaminathan said. “These are things they can use while they’re boarding.”
Strategies to reduce ED boarding: Hallway beds and discharge lounges.
Cooper University HealthCare deploys two different interventions to relieve ED boarding. Read more here.
Strategies to reduce ED boarding: Surrounding patients with outpatient resources.
Lehigh Valley Health Network has put in place a triage process that clinicians use with all patients presenting to the ED. Read more here.
Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.
