Length of Stay is Here to Stay – Why It Matters and How We Can Help

By Matthew Reeves, DO, chief of integrated care, Premier Health

My name is Dr. Matthew Reeves, and I was the former chief medical officer (CMO) at Atrium Medical Center. I now serve as Premier Health’s chief of integrated care. Opinions likely vary as to what “integrated care” means, and you might be wondering, “What is the significance to my patients and me?” This new division will be coordinating the efforts of case management, social work, clinical documentation improvement, the statusing team, our hospitalist group, and our newly formed physician advisor group. By bringing this team together, we believe we will be better able to coordinate our efforts and assist you in providing high quality and high value care for your patients and the communities we serve as a whole.

Certainly, the acute care continuum will be a primary focus of our work. We will also be ramping up efforts with our new Care Transitions Program. This approach will allow us to work with our internal partners and better collaborate with our post-acute care partners (e.g. Fidelity Health Care, independent and Premier Physician Network physician groups, extended care facilities, as well as others) to ensure your patients’ needs are fully met through the entire continuum of care.

With that introduction, let’s focus on Length of Stay (LOS). Please don’t stop reading, as this has tremendous importance for physicians. While we made tremendous progress in 2018 (thank you!), length of stay has more recently been trending up at several of our facilities. Since the 1980s with the inception of the CMS Prospective Payment System (PPS), hospitals have been measuring LOS as a common quality metric. Physicians have grown weary of case managers and administrators “hounding” them about “their” LOS. Many physicians just see LOS as a financial performance indicator of hospitals that we put on the backs of our physicians. This is a team effort, and we all own a portion. This team includes ICM and the others I named above, in addition to nurses, doctors, and our essential partners in lab, imaging, and other service departments. Together, we are able to identify our opportunities for improvement. While we cannot deny that LOS has financial implications, that is not the sole real reason why we focus our efforts on LOS.

So, why should LOS matter to you as a physician?

Clinically, there is a large body of evidence in the literature that demonstrates the association between adverse events in the hospital and LOS. The longer your patient is in the hospital, the greater the risk of hospital-acquired complications (e.g. secondary infections, falls, procedural, or pharmacy errors) and patient safety indicators. Yes, sometimes complications lead to longer lengths of stay, but most of the time it’s the reverse. Intuitively, it seems that a longer LOS would lead to fewer readmissions; however, there’s very little evidence to support that. A study looking at 14 years of data from the VA showed that both LOS and readmissions can be reduced together; and that in the subset of hospitals with higher readmissions, some had a lower average LOS, while some had higher LOS with no correlation. Thus, our goal should be to work as a team to provide the highest quality care at the appropriate level of care and lowest cost possible. If we focus on that, our LOS will improve.

Here are a few tweaks in practice patterns that can make large differences and even improve the patient experience:

•  Schedule operations strategically – i.e. if you know your patient will require a 24- to 48-hour post-op recovery before being safe for discharge, don’t perform those cases on Thursday or Friday if a weekend discharge is not possible.
•  If you are a consultant, document clear discharge parameters for the primary attending, and/or communicate back to the attending promptly. (And if you have not heard about Epic Secure Chat, let your CMO know.)
• As much as possible, think about which tests and/or procedures can be done as an outpatient and make those suggestions early in the patient’s stay so appropriate arrangements can be made.
• Discuss goal of care early in the stay and set patient/family expectations for discharge plans, communicating that to the whole care team clearly in the chart. 
• Palliative Care is a hugely underused resource for disease and symptom management.

The Integrated Care Team looks forward to working with you and supporting our team of CMOs. Please do not hesitate to reach out to me or anyone on my team with questions, suggestions, or requests for assistance.

Chief of Integrated Care – Dr. Matthew Reeves, chief of integrated care, (937) 499-9740(937) 499-9740, msreeves@premierhealth.com

Integrated Care Management – Ronald J. (R.J.) Francisco, system director, integrated care management, (937) 208-5286(937) 208-5286, rjfrancisco@premierhealth.com

Center for Status Integrity – Kimbra Kahle-Paden, department director, clinical denials administration, (937) 208-2095(937) 208-2095, KLKahlePaden@premierhealth.com

Clinical Documentation – Jeanne Johnson, system director, clinical documentation,(937) 440-4259(937) 440-4259, jcjohnson@premierhealth.com

Physician Advisor – Andrew Maigur, MD, system director, physician advisor program, (937) 208-8394(937) 208-8394, abmaigur@premierhealth.com

Hospitalists – Jeffrey Poulos, MD, chief hospitalist officer, (937) 208-8394(937) 208-8394, jgpoulos@premierhealth.com 

Back to the June 2019 issue of Premier Pulse