The Task Force on Reducing Length of Stay for Patients Served in DRG 209

Members: Joseph A. Buckwalter, MD, Chair, Daniel Fick, MD, Steven Lillehaug, MD, Gloria Van Milligan RN, Terri Stoner and Ameet Mehta.

Assisted by Bruce Miller, Linda Fink, Jean Teale, Carolyn Rourke, Martha Blondin, Jan Christensen, Cheryl Reinhardt, and Dan Coons.

The Task Force charge was to review DRG 209, "Major Joint and Limb and Reattachment Procedures of Lower Extremity." Based on comparisons to peer University Healthsystem Consortium (UHC) hospitals, UI Hospitals and Clinics has a savings opportunity of 506 days (during FY 99-00), and a savings opportunity of 405 days based on first nine months of FY 2001. (Information taken from Exhibit I)

2. Results of Analysis

The Task Force performed an extensive review of data from 2000 to 2001.

A. Discharges, Length of Stay

Inpatient data for 312 patient discharges within DRG 209 from July 2000 to March 2001 were studied. The Task Force focused on five principal procedures within DRG 209, which resulted in 296 discharges. Those five surgical procedures in order of opportunity were: (Information from Exhibit II)

• Total Hip (procedure code 8151) Percent of total discharges was 35.5% (Savings Opportunity of 115 Days)
• Total Knee (procedure code 8154) Percent of total discharges was 38.1% (Savings Opportunity of 96 Days)
• Revision Hip (procedure code 8153) Percent of total discharges was 10.4% (Savings Opportunity of 94 Days)
• Revision Knee (procedure code 8155) Percent of total discharges was 7% (Savings Opportunity of 38 Days)
• Total Ankle (procedure code 8156) Percent of total discharges was 9% (Savings Opportunity of 34 Days)

In total: The observed average length of stay (ALOS) within this group was 5.79 days vs. an expected ALOS (calculated by University Healthsystem Consortium) of 4.52 days, resulting in a LOS Index of 1.28 days and savings opportunity of 376 days (Exhibit III). When compared to 15 comparable UHC hospitals with a comparable case volume and with at least 50% of patients having Medicare as their primary payor, UI Hospitals and Clinics had the highest observed ALOS, LOS Index as well as savings opportunity in days. (Exhibit IV) However, when compared by number of patients discharged to home, the observed ALOS for UI Hospitals and Clinics was comparable to other UHC hospitals in the Midwest (Exhibit V).

B. Skilled Nursing Facility, Medicare Patients: Our Greatest Opportunity!

Analysis of patient demographics revealed that the majority of patients are discharged to home, followed by those to a skilled nursing facility (SNF) and then to home under a home health agency. (Exhibit VI) Based on our analysis we find the maximum of savings opportunity for those who are on Medicare and are going to SNF. Note: We are comparing ourselves to best performers who have in-house or next-door SNF.

I. Those discharged to a SNF had the maximum savings opportunity of 181 days

Barriers:

1. SNFs don’t always have beds available when the patient is ready for discharge.
2. Patients often limit the number of facilities they are willing to consider and don’t want to go outside their geographical area. (i.e. home community)
3. SNFs do not admit patients on weekends (Sat/Sun) due to rehabilitation requirements set by Medicare.
4. Even it a patient plans ahead and indicates to a facility prior to surgery of their intent to go to SNF after surgery, a bed may not be available as facilities don’t always hold the bed. (They lose money if it sits empty)
5. The medical complexity of our patients makes it difficult to find placement at times. SNFs decline to admit patients if their staffing levels are low.
6. Some patients do not have insurance that will cover this type of care.
7. Patients do not feel well enough to transfer to a SNF.
8. Some SNFs are reluctant to take patients if they are on certain IV medications for which reimbursement is not provided by certain payors.
9. Some require VRE testing and an onsite visit by their staff before agreeing to accept patients. This adds at least another 1 to 2 days to the waiting times for the SNF to call back with a decision to transfer or more questions.

II. Patients discharged to home had a savings opportunity of 105 days

Barriers:

1. Patients do not have transportation. Over 66% of patient discharges in July and August were delayed after 11 AM due to transportation problems.
2. Patients have expectations of longer stays and are reluctant to leave, or families do not feel comfortable taking the patient home.
3. Discharge orders do not get signed in time for early release (22%).

III. Patients discharged to home under the care of a home health agency had a savings opportunity of 62 days

Barriers:

1. Patients do not have health insurance coverage for home health care (i.e. State Paper patients who need blood work done locally or who need physical therapy)
2. And most of the same barriers from above!

More than 50% of our patients have Medicare as their primary payor. The majority of the patients discharged to a SNF have Medicare as their primary payor. Overall, Medicare patients account for approximately 80% of the savings opportunity in days (295). (Exhibit VII) A review of Admission and Surgery Days which are on Monday, Wednesday and Friday in the main OR, demonstrates that if we could schedule our patients who are identified as Medicare and as going to skilled nursing facilities for surgery on Mondays or Fridays combined with advanced discharge planning, we could significantly reduce LOS.

C. Patient Scheduling, Physical Therapy, Discharge Planning and Care Issues:

Discussions were held with a multidisciplinary group including representatives from Department of Nursing Services and Patient Care, Orthopaedics, Rehabilitation Therapies, and Social Services. We discussed and evaluated the process of care for this group of patients. In addition, telephonic conversations were held with the University of Alabama Health System, Emory University System of Health Care, The University of Washington Medical Center, (the best performers) to learn about their process of care. Recommendations from these discussions are included in our final implementation plans.

D. Major OR Resources and Implant Cost Issues:

Discussions were held regarding purchasing practices, expense and use of supplies and implants with the Perioperative Nurse Manager, and the Administrative Assistant, Perioperative Nursing Division of Nursing Services and Patient Care (the budget area for these products). The majority of UI Hospitals and Clinics hip (80%) and knee (85%) surgical implant products are standardized with one vendor (from the seven available), Johnson and Johnson. We are receiving a 33% discount over list price for these implants, which is very favorable pricing when compared to other institutions. The revision procedures are dependent on the brand of implant previously used, so may not conform to our standardized implant product. Overall, the number of usage orthopaedic implants increased (based on the top 100 most expensive implants, 176 in 2000 to 370 in 2001) 121% since last fiscal year. The average cost per case for hip implants is $5,771, and for knee implants it is $4,180. (These numbers came from discussions with Nurse Manager Lisa Feeney.) One success in this area will be to claim UHC patronage distribution funds from the use of ortho implants which we had not taken advantage of prior to this team. This savings has been estimated at $60,000. This cost information will be provided to another Surgical Services task force looking at all implants costs.

3. Statement of Recommendations

Recommendation 1: Develop a Steering Committee of Orthopaedic Surgeons to oversee a multidisciplinary team to accomplish the following recommendations.

Departments and Staff Responsible for Implementation of Recommendations:

Department of Orthopaedics:
Dr. Joseph Buckwalter, Chair
Dr. Richard Brand
Dr. Charles Clark
Dr. John Callaghan
Dr. John Marsh
Dr. Mike O’Rourke, Resident

Timelines for Implementing Recommendations: Team meeting by October and follow-up meetings quarterly.

Evaluation: Monitor LOS for these patients. Monitor other outcomes such as patient satisfaction and any new readmissions. Provide quarterly reports to DRG 209 Task Force.

Departments and Staff Responsible for Implementation of Recommendations:

Department of Orthopaedics: Dan Coons
Department of Rehabilitation Therapies: Bruce Miller
Department of Nursing Services and Patient Care: Carolyn Rourke
Department of Social Services: Jean Teale, Cheryl Reinhardt

Evaluation: Monitor ALOS for patients discharged to skilled nursing facility. Report to the Steering Committee to insure this is being done.

Departments and Staff Responsible for Implementation of Recommendations:

Department of Orthopaedics: Dr. O’Rourke, and Linda Fink
Department of Rehabilitation Therapies: Bruce Miller
Department of Nursing Services and Patient Care: Jan Christensen, Martha Blondin

Evaluation: Monitor ALOS (especially Medicare patients and patients discharge to home). Monitor readmissions for any unsatisfactory changes

A. Pre-op environmental assessment
B. Pre-op practice of skills that will be needed post-op.
C. Greater involvement of family/ caregiver in the post-op care provided during hospitalization.

Departments and Staff Responsible for Implementation of Recommendations:

Department of Nursing Services and Patient Care: Mary Nace, Carolyn Rourke
Department of Social Services: Jean Teale
Department of Rehabilitation Therapies: Bruce Miller

Timelines for Implementing Recommendations: October 2001

Evaluation: Monitor ALOS. Report to the Steering Committee to insure this is being done.