"Extend the Chain": Work with Resources Outside of the Hospital to Improve the Flow of Care

Responsibility driven by geography — that is, addressing only those problems in one’s own area — is the source of much variation in hospitals. Particularly for hospitals with patient flow problems, working with physicians and long-term care facilities outside the hospital — i.e., those with the power to impact both admissions and discharges — is an effective strategy to improve flow.
 
A common bottleneck in the ICU, for instance, is the inability to transfer chronic ventilator patients off the unit because there are not enough ventilator beds in other settings. One hospital solved this problem by partnering with an unaffiliated nursing home. The nursing home was able to open a ventilator unit because the hospital assigned an intensivist to serve as a part-time medical director for the unit. This helped improve flow out of the ICU and provide predictable income for the nursing home, and also resulted in high-quality, lower-cost care for the patients.
 
Other approaches to "extending the chain" include:
  • Predict admissions to extended care and work with those providers to develop plans to meet the demand
  • Provide a physician assistant or nurse practitioner to make regular rounds in extended care facilities, preempting visits to the emergency department for episodic and acute care
  • Utilize or expand the capabilities of the nursing home to do clinical diagnostic testing and treatment to avoid unnecessary transfers to the hospital setting
  • Partner with out-of-hospital care providers to promote advanced access scheduling (sometimes referred to as "open access") in physicians’ offices so patients can get timely access to ambulatory care in an appropriate setting, rather than resorting to the hospital emergency department
  • Work with hospice services in the community to help assure that end-of-life care is provided in the most appropriate, but least intensive, setting

 

Partner with a Local Nursing Home to Open a Ventilator Unit

A common bottleneck to the efficient flow of patents into and out of the ICU is the inability to transfer chronic ventilator patients off the unit because there are not enough ventilator beds in other settings. One hospital solved this problem by partnering with an unaffiliated nursing home. The nursing home was able to open a ventilator unit because the hospital assigned an intensivist to serve as a part-time medical director for the unit. This helped improve flow out of the ICU and provide predictable income for the nursing home, and also resulted in high-quality, lower-cost care for the patients.

 

Tips

  • Empower nursing home staff by training and educating them on the care of ventilator patients.
  • Make successes visible: post positive results (weaned patients, patient satisfaction scores, staff satisfaction scores, etc.) to get people excited about making changes.

 

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