Ready, Set, STOP! How to Discharge Difficult-to-Place COVID Patients

by Mary Kay Thalken, RN, MBA on Jul 10, 2020

Waiting PatientIt’s happened to all of us in the case management field.

You have a patient who’s ready to take the next step in their recovery. Their acute stay is complete, they’ve selected their preferred post-acute facilities, and you’ve begun the process of communicating with those providers to determine if they have the capacity to take on your patient.

Then you start receiving replies: No. No. No.

So you try again. You go back to the patient to apologize and tell them their initial choices aren’t accepting patients. You create a new list of potential facilities and communicate with them.

No. No. Maybe (and then you follow up to find…no).

This is a frustrating situation at the best of times, but during the COVID-19 pandemic, it’s particularly disheartening. COVID-19 is straining capacity of our nation’s hospitals, and the highly transmissible nature of the virus also means many post-acute facilities that would traditionally accept patients are unwilling or unable to take on those recovering from the coronavirus. Hospitals end up with patients stuck in a bed even as waves upon waves of additional patients are coming in right behind them.

How do you resolve this dilemma? There’s no perfect solution, but you can follow a few best practices to increase the chance that a patient is able to be discharged to the LTACH, SNF, IRF or any other facility where they’ll be able to progress in their recovery.

Have a List of COVID-Ready Facilities…And Track Capacity

The best initial step you can take, if you haven’t done so already, is to create and curate a list of all post-acute care (PAC) facilities that are currently accepting COVID patients.

This can itself be broken down into smaller steps. First, compile your list. Ideally, the solution you use to automate the discharge process has a feature that highlights whether or not a PAC is accepting COVID patients. If not, you have a lot more work ahead of you, as you’ll have to reach out to these facilities on a regular basis to see their status and monitor if anything has changed.

Once you have the list of PACs that accept COVID patients, set up a process wherein you double-check the status on a weekly, biweekly or, at the very least, monthly basis. To be at your most efficient, you don’t want to have any surprises awaiting when you seek to place a patient.

As you go about placing patients, ask a PAC representative what their current capacity looks like. Just because a facility can accept patients doesn’t mean that they’re always able to do so. They might have a relatively small number of beds in a separate unit set aside for COVID recovery cases. You’ll want to know this number and be updated when they’re almost full. Ideally, they would send a note to let you and other hospitals in the area know when they’re at capacity, but that isn’t always the case. You might have to be pretty proactive to track this information.

Finally, keep a database that everyone on your discharge and case management teams can access and edit as they discover more information.

Traffic LightQuickly Update Your PAC Network

Never before have hospitals’ networks of potential post-acute facilities fluctuated so greatly in such a short period of time. As local governments and larger health systems respond to surges in cases by co-opting hotels, PACs and other buildings for the purpose of supporting the treatment and recovery of patients, your post-acute network is undergoing a level of change that case managers are unaccustomed to.

In order to have the best chance of discharging your patient to an appropriate setting, you need a running list of what settings are available. This certainly isn’t easy, but you can do a few things to help your team out.

First, you need an electronic database of available organizations, which we’ve already mentioned. But more than that, you need to be able to add and delete facilities on the fly. It’s imperative that you have a software solution that accommodates this need, otherwise you simply can’t keep up with the demand of the current healthcare landscape.

Keep your finger on the pulse of the local news and the current pattern of COVID cases. Hopefully, someone at your organization acts as a liaison to your city, county or state health departments. This role can relay information about new facilities, allowing you to update your catalogue accordingly. If not, communicate with hospital leadership the value in this proposition and how it can help you get patients out the door more quickly upon recovery.

This is also a great time to have a “hotlist” of preferred providers whom you know can reliably take on difficult-to-place COVID patients. This would be those organizations that have a great track record of safety, the appropriate infection control protocols and exceptionally high capacity.

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Don’t Skip the Details

In some areas, standards have been set requiring, for instance, a patient to quarantine for two weeks at the PAC or to have a negative test result 48 hours prior to discharge. In other areas, these parameters might be piecemeal, with each individual PAC creating their own rules. And even in the areas with standards set by the Department of Health, the PACs might have additional rules that exceed those standards.

This scenario requires you to track a gigantic amount of information. The best way to do so could be to allow editing privileges to everyone on the team who has contact with PACs. That way, they can make notes and edit the PAC’s provider profile in your system. These notations can spell out things like testing requirements, capacity, transportation processes, infection control procedures, and other standards for accepting patients.

You might be sensing a pattern here: much of what we’ve listed as a best practice hinges on carefully tracking and updating all available information so that your discharge team is working off the latest updates without having to manually track down those details every single time. If hospitals work as a team to acquire the most recent details, no matter how granular they may seem, and then you include that information in a database everyone has access to, you can save critical time and potentially get your patient out the door more quickly.

This issue requires systemic change and constant vigilance, but it will be worth it when it comes to keeping capacity as low as possible. And when this is all over, whenever that may be, you’ll have an adaptable system set up well for the future.

Teleheatlh from HomeHome Health

One scenario we haven’t touched on yet is home health, which comes with its own complications. But if you take the proper precautions, this can be a good opportunity to free up bed space and improve the patient experience by giving your COVID patient the chance to recover in a setting where they’ll be most comfortable.

You no doubt have parameters governing what qualifies an individual to continue their recovery at home rather than at the hospital or in a post-acute care setting. We certainly wouldn’t presume to offer clinical guidance in that regard. But we would encourage you to think about what you could do to expand home health candidacy and make the experience as pleasant as possible for patients.

For instance, what kind of initiatives do you have in place to ensure the social determinants of health are being addressed for the patient? If that individual is in quarantine within their home, does he or she have a scheduled prescription delivery or access to a steady stream of groceries? Do they have a means of safely making it to appointments, or access to high-speed internet that makes telehealth possible?

In some cases, if you can attend to the patients’ needs, you might be able to take a patient who would otherwise have no choice but to stay in the hospital and allow them to recover at home. The cost of scheduling grocery delivery or setting up a telehealth app pales in comparison to the cost of that patient undergoing an extended hospital stay.

The past few years have seen plenty of talk about strategies that extend hospitals’ purview beyond the hospital. COVID-19 has shown in great detail just how important these initiatives can be for both recovery and revenue.

As capacity becomes an issue, hospitals will no doubt get more creative than ever with figuring out who might qualify for home health, especially if a majority of PAC facilities are out of the question. Even if it requires additional staff or resources to check in on the patient and ensure they’re progressing properly, this could be the right move for a number of patients who would otherwise be underserved in a hospital setting.

Ready, Set…Here We Go

We’ve all thrown around the word “unprecedented” a lot lately, but really, how else can you describe what’s happening? COVID-19 is causing all of us to rethink every process we have, and discharge is no different, particularly when capacity is such a critical component of the proper provision of care.

If you have difficult-to-place patients and have come up with creative ways to solve for discharge, please let us know in the comments. Share any best practices you may have, and continue to check back as we share what we’ve discovered in our conversations with hospitals and PACs.

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Meet the Author

Thalken brings more than 30 years of experience in health-care leadership to our company. Prior to joining the company, she served as Enterprise Vice President for Care Logistics in Atlanta, Ga. She has held executive leadership positions at hospitals in Nebraska and Iowa, including the position of System Quality Executive for Alegent Health. Thalken has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. Thalken holds an MBA from the University of Nebraska at Omaha. She is a member of the American College of Healthcare Executives, American Organization of Nurse Executives and American Case Management Association.