Investment in Transitional Care Pays Off for Busy ED

Hubert Wong , MD

Published June 18, 2014

To help our hospital clients improve patient outcomes and better serve their communities, Vituity has piloted a role called the transitional care director (TCD). The TCD is a physician who works to improve care transitions across the Acute Care Continuum by implementing sustainable, systematic change.

I'm now in my second year as TCD at Orange Coast Memorial Medical Center in Fountain Valley, Calif. In this role, I have been privileged to work with our administration, hospitalist groups and community organizations on several improvement initiatives.

Today I'll share our goals for the position, plus of few examples of how greater investment in transitional care has benefited our patients.

A Rationale for Better Transitional Care

Historically, emergency physicians have provided "episodic" care that doesn't necessarily follow patients across settings. However, last year's landmark analysis by RAND highlighted the evolving role of the emergency department and the need for coordinated care within this setting.

Specifically:

EDs have become an important source of primary care, especially for the uninsured.
About half of all hospital admissions now originate in the ED.
Primary care doctors often refer patients to the ED to determine whether admission is appropriate.

Given these facts, it's clear that each transition from the ED to a new setting has implications for both the patient and hospital.

Without appropriate follow-up care, many patients discharged from the ED will return in worse condition. Poor communication between emergency and hospitalist physicians can compromise safety and quality. And emergency physicians often feel they have no choice but to admit patients who lack reasonable access to appropriate post-acute care.

Managing Managed Care

Like all EDs, Orange Coast Memorial has unique needs. Perhaps the most pressing of these is throughput. We currently handle about 30,000 visits a year with just 18 beds.

What's more, our acuity mix is high, with 30 percent of our ED patients admitted to the hospital. Because our region is dominated by managed care, this requires collaboration with five separate hospitalist groups that regularly admit to our medical center. Each group has its own admissions process, and they vary in terms of their staffing practices and emphasis on utilization.

Fortunately, our ED medical director Robert Realmuto, MD, had a vision to bring these stakeholders together at one table. To this end, he facilitated the formation of a Joint ED/Hospitalist Operating Committee comprised of an ED representative, the directors of our five largest hospitalist groups and case management.

Over the past several years, committee members have worked toward our common goal of improving integration and patient flow across the Acute Care Continuum — starting in the ED and continuing through admission and ultimately discharge.

As TCD, I took over leadership of this committee and have benefited greatly from the groundwork laid by our members.

A Collaborative Approach to Patient Flow

Bringing the leaders of our ED and hospitalist groups together in the spirit of cooperation allows us to share best practices and engage in joint problem solving. A recent example was our work on turnaround time to admission (TAT-A).

When the ED is ready to admit a patient, we generally put out a call or page to the appropriate hospitalist group. Our data showed that four of our five hospitalist groups responded by issuing an admission order within 15 minutes. However, one (the largest) took an average of 70 minutes to initiate the admission process.

At our committee meeting, representatives from the outlier group discussed their strong focus on utilization. They believed it was important for the hospitalist to personally evaluate the patient in the ED before entering an admission order. Reviewing the data really helped this particular group see the impact of its process in a nonthreatening way. While their approach certainly had merit, it also impacted patient flow throughout the hospital.

Fortunately, the committee came up with a solution that worked for everyone. When a patient of this group meets certain criteria that strongly indicate the need for admission, the emergency physician notifies the hospitalist by phone, then enters an admission order and expedites a bed request. This allows us to begin moving "definite" admits upstairs without having to wait for the hospitalist to complete their evaluation in the ED.

While we're still gathering outcome data, this practice has had a noticeable impact on patient flow across the hospital, and I'm very much looking forward to taking our updated numbers back to the committee.

One lesson I've learned as an ED physician working with five hospitalist groups is how important it is to bring solutions to the table. Rather than just asking the hospitalists to help us, we need to think of ideas that also make their lives easier by helping them manage utilization and meet their group's care goals.

Working with the Community to Reduce Readmissions

Another priority at Orange Coast Memorial has been reducing readmissions. This is a particularly salient issue for the ED as it's one area we can make a significant impact.

I know from experience that when it comes to admissions, emergency physicians often feel between a rock and a hard place. It's extremely tempting to admit a recently discharged patient who returns in a dehydrated state or struggling with pain management — especially if the person lives alone or has poor access to follow-up care.

As a potential solution, I recently organized a meeting with five local skilled nursing facilities (SNFs) to which our patients are commonly transferred at discharge.

Working together, we have developed a standardized order set designed to streamline the transfer process. These allow any ED or hospitalist physician to initiate the admission to the SNF, resulting in expedited transfers and reducing boarding time in the ED. Each SNF also designated a contact person to help tackle any issues.

To date, we've completed several successful ED-to-SNF transfers, and I expect to see many more in the future as we continue to refine the process.

Overall, we found the SNFs very receptive to working with us. One lesson I learned is that it's generally most effective to meet with SNFs one-to-one (versus bringing everyone to the table), because the inherent business competition between the local SNFs made individual meetings more productive.

In conclusion, investment in transitional care, including the creation of a transitional care director, has already paid off for Orange Coast Memorial. I look forward to working with our hospital and community stakeholders to further enhance transitional care for our patients.

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