Optimization of Patient Progression in a New Era: A Comprehensive Framework

PURPOSE/OBJECTIVES

The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments.

PRIMARY PRACTICE SETTINGS

Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign.

FINDINGS

Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days).

CONCLUSIONS

Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration.

Survey Study of a Hospital-Based Bereavement Program During COVID-19: Insights to Improve Support of the Bereaved

Background: The COVID-19 pandemic has highlighted that bereavement care is under-recognized with few hospitals offering universal bereavement services. Methods: One hundred sixty-nine bereaved individuals, whose loved ones died at our hospital during 2021 and 2022, completed a survey about their experience with the bereavement program. Results: Of respondents who recalled receiving bereavement outreach, 79% rated speaking to a team member soon after the death as having a positive impact on their bereavement, and 75% rated receiving a condolence call or note from the team positively. Feedback also identified opportunities for improvements in care: (1) importance of compassionate communication and connection with family members after a death; (2) more flexible hospital visitation policies; and (3) additional support for families during the end-of-life (EOL) period. Conclusions: The findings demonstrated that a hospital-based bereavement program can positively impact an individual's bereavement experience with a formal letter of condolence, psychoeducation information, and direct outreach from team members soon after death, being positively evaluated.

An Academic Medical Center-Based Incubator to Promote Clinical Innovation and Financial Value

INTRODUCTION

Within a health care landscape characterized by increasing financial pressures, fluctuating payment models, and an increasing prevalence of clinician burnout, structures to strategically support innovation are imperative to financial and clinical success.

METHODS

We developed the Brigham Care Redesign Incubator and Startup Program (BCRISP), a flexible model to test, evaluate, and scale innovative care redesign proposals. We evaluated its impact via analysis of programmatic and financial data, as well as through exploration of individual project outcomes.

RESULTS

In 5 years, BCRISP has evaluated 283 innovations, piloted 25 projects, and generated $1.8 million in total medical expense reduction and $7.1 million in increased net revenue for our institution. Initially, it was conceived as a mechanism to engage staff in population health initiatives. As shifts toward risk-based reimbursement have slowed, we have observed a similar transition among proposed and supported innovation in the program.

CONCLUSIONS

BCRISP enabled front-line clinical employees to design and pilot solutions to common and important clinical care problems, delivering financial return and improvements in care delivery. The underlying structure has been able to adapt to the changing political and economic climate, demonstrating a flexible and powerful approach to strategic investment that could be applied broadly by many health care provider organizations.