Every health system leader has unprecedented executive management challenges facing their organization in the wake of the pandemic. One of those vexing problems that we continue to see today is deciding where a patient should go, especially with reduced hospital and post-acute capacity. Diving deep into this mismatch between demand and capacity, Gina Kidder, MSN, ACM-RN, joins us in this episode. Gina joined ABOUT Healthcare in 2023 as Client Outcomes Engineer, with more than 30 years of experience in healthcare across nursing, HCIT implementations, and Care Management. She brings her expertise on care orchestration and patient transitions to help us navigate this issue that has been affecting how patients receive the right and proper care. Following the theme on Taking Control of Throughput, Gina talks about using data and technology to create better strategies and decisions. Join Gina along with Dr. Chuck Peck, Ben Sawyer, and Darin Vercillo to learn more on improving patient care in this conversation.
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Demand And Capacity: Deciding Where A Patient Should Go With Gina Kidder, MSN, ACM-RN
This show is brought to you by the Malcolm Baldrige Foundation and our strategic partner, ABOUT Healthcare. I’m happy to be joined by Ben Sawyer and Darin Vercillo, both executives at ABOUT Healthcare. For those of you who are the regular audience, you know that we’ve been focused on leadership and change management topics over the past several broadcasts. In this episode, we’re going to move into something that’s very tactical and operational and something that I know has been a vexing problem for most health systems in the country, especially since the COVID pandemic that has continued because of a lot of the issues around staffing, etc.
What we’re going to talk about is deciding where a patient should go in this age of reduced hospital and post-acute capacity. There’s a significant mismatch between demand and capacity. I’m sure you’re all aware. You’ve read articles about some patients having to sit in beds and hallways in the emergency room for 1 or 2 days. It’s become a serious issue.
What’s even more vexing and problematic is that even though those patients are in the ICU waiting to get a bed on the floor, or in the emergency room trying to get a bed on the floor, if you walk around the hospital, you can see that there are beds sitting there that are empty, yet we can’t fill them because we have severe shortages in so many areas, as well as other things that are going on.
What we’ve decided to do is talk about that issue. We have somebody who’s extremely well-versed as our guest to help us get through this. Gina Kidder joined ABOUT Healthcare in 2023 as a Client Outcomes Engineer. Gina has many years of experience in healthcare across nursing, healthcare information technology implementations, and care management.
Her role provides health systems with real-time and ongoing insights to ensure their strategic plans around care orchestration and patient transitions and make sure that those are on track for success. Before joining ABOUT, Gina became an RN after working on EMR implementations for Shared Medical Systems and worked as a Trauma Nurse Clinician for a Level 1 trauma team in suburban Chicago.
She transitioned to care management helping lead nurses and social workers in academic and community hospital settings prior to the challenging pandemic starting in 2019 and throughout. We’re going to lean on Gina, Darin, and Ben, who I know have a lot of experience in this area to try to figure out if there are any things that we can do differently or use technology in better and more advanced ways in order to help with this difficult issue. Welcome, Gina. It’s great to have you here.
Thanks for having me.
I know you spent a lot of time in the emergency room. You were in a Level 1 trauma organization. What we can first do is lay out what seems to be a big issue. We have all this IT infrastructure now, including EMRs and everything else, but we don’t seem to be able to use data to help us identify what the real problem is and what the ideal solutions might be. You could start by laying out what you see as the problem causing these issues with getting patients placed in the appropriate place. This can be either in the hospital or even in the post-acute space, which I know is a huge issue that’s keeping us from finding some beds for people who need them.
The post-acute space is one of the biggest areas where we’re seeing so many challenges with throughput. I was reading a Minnesota newspaper article that reported 22% of the patients in Minnesota hospitals are those waiting for post-acute services. They’re medically cleared for discharge, and they just can’t go yet for whatever that reason.
It’s important as organizations to break down some of that data that they have to get a good glimpse of what their payor mix looks like, especially in the care management department, and be able to connect what that payor mix looks like to their care managers on the front line so that they can direct the next site of care appropriately and efficiently.
You don’t want to have anybody wasting time on an inaccurate next side of care because with the prior authorization requirements for Medicare Advantage plans, you could spend days chasing a dream that’s not going to ever happen. You may not get that authorization. It’s having a team that’s well-versed in the payor mix and knowing what those obstacles are going to look like.
Also, taking that data and using it to give to your contracts department so that they can look at it to see if there’s something they can negotiate with some of the heavier payers that you have in your payor mix. That’s something that is really important. Also, getting a good knowledge of what your skilled nursing facility utilization is, and whether is it appropriate. We don’t want patients going to skilled nursing facilities and waiting for them when it’s not the appropriate next site of care.
It’s having a home-first type of mentality as an organization and making sure that message gets down to the multidisciplinary team. Use your data to know how many of your patients are going to home health, how many are going to the skilled nursing facility, and how many are going home, and then making some strategy decisions based on that.
Darin, what I hear a lot is that we have “reams and reams of data,” but we don’t have actionable information. A lot of the data that we have isn’t integrated. We’re not fully utilizing our analytics teams, integrating them into the other teams and leadership in the organization. I know that both of you have experienced particularly what ABOUT does is its primary reason for being. Maybe you could talk a little bit about that and some of the successful ways that you all have seen organizations use data in a meaningful way.
First of all, Gina, thank you. You set the stage and Chuck for a very germane discussion of what’s going on in the industry. Without trying to get too far off on a rant with some of the things that I’ve seen on my practice side of the world as a hospitalist, there are a couple of things I wanted to comment on.
We do have reams of data, and we’re just not leveraging it. We look at it too late in the game. We don’t attach it to the decisions that are being made. Going back to some of the things that Gina mentioned, we have such a traditional cadence. A patient comes into the hospital. We pay lip service to say, “Discharge begins with admission. We’re going to start looking at it,” yet, taking that one thing that Gina mentioned and getting authorizations, we get down to the end of the patient’s day. We start looking for a skilled nursing facility.
It’s Friday afternoon or Thursday afternoon and we call the insurance company. Now, we’ve got the patient sitting in there waiting for authorization for the entire weekend, and we’ve got a bed block. To that point, I’d like to change the moniker in our entire industry from finding a bed to finding a nurse nowadays. To the point it was made, half the hospital can be empty and we’re turning patients away because we have beds. We just don’t have nurses to take care of. Call them staff beds or what you will.
I was talking to an ER colleague of mine. I know this changes from the hospital system’s geographical size of the hospitals. There are some that have been able to staff back up and get close, but the majority of the industry is still suffering from this. It was almost like during the pandemic time by ER Dr. Collie told me that she had transferred out ten patients that night before because we didn’t have nurses to take care of those patients.
It was almost like back in the pandemic when the hospital was 110% full, and they were making phone calls to 27 different hospitals to take that next COVID patient because we didn’t have capacity then. That was pure capacity in beds. Now, it’s nursing. These are huge issues. Here’s one thing I want to plug into this before I hand the floor to Ben because I know he has comments on this too.
I feel like the data that we have, the methodology that we use, and the people that are involved are going to all be brought together through appropriate communication at the appropriate timing. We need to start communicating earlier from the hospital side to the post-acute care side, getting them involved earlier so they know that we’re coming, and getting involved earlier in discussing this with the payers so we can get those decisions made and overcome the delays that happen right at the end.
Last but not least, it’s been very interesting in my practice in hospitalist and critical care medicine that I will come on for a night shift. At 5:00, I’ll get a couple of admissions from the ER, and then I’ll get a call from the nursing supervisor who’ll say, “We’re out of beds. We’re out of nurses,” yet a couple of hours later, I’ll hear back from them again, “We got another admission.”
They’ll trickle in all night long because they find ways to play musical chairs and move the patients around, and musical nurses and move the nurses around, or they’ll get a float nurse in. We have data here. We have to get better at predicting, getting insights, and understanding what the night or day is going to look like and not just be so reactive.
We’ve got the ability whether it’s algorithmic approaches or machine learning to be able to look at this data, look at the situations, and know what we can do rather than this being such a conundrum and a messy fight all day and night long as to whether or not we’re going to be able to give the appropriate care to those patients in the right place at the right time.
Darin, before we move on to Ben, just a specific question, where is all of this data located? These systems have spent millions of dollars on the electronic medical record, thinking that this was somehow going to be a panacea for this. We all know that where the electronic medical record has probably been the most help, unfortunately, for patient care is on the revenue cycle. Where should people go to look for this data? How should they think about integrating it in a way that allows them to do some of the things that you just talked about?
Getting back to where you did the introduction on the executive side at ABOUT Healthcare with Ben, and of course, Gina works with us as well, this is where we bring that information together. The data’s there. It’s just not connected or being analyzed appropriately until you bring in somebody like ABOUT who focuses on those specific metrics, KPIs, and utilization of that existing data. Whether it’s weeks, months, or years of information that includes capacity data, staffing data, admissions data, and transfers data.
When you bring that all together, it suddenly becomes very clear that you can set the scoring, the thresholds, and the decision-making in the dashboards that we love to present to executives in real-time so those decisions can be made. The short answer to your question, the data and information generally already lie within the data warehouses and the systems that we come in and connect together and make the magic happen.
I had a conversation with KLAS, which is the organization that evaluates all vendors on behalf of provider systems. They’re doing a survey that they will ultimately be publishing. One of the key insights that came out of that, which was consistent feedback from every health system is we are data-rich and we are insight poor.We are data rich, and we are insight poor. Click To Tweet
It goes right to what you talk about, Chuck, which is they have reams of data. It’s in their data warehouses and business intelligence systems. They just don’t have the insight. A lot of it has to do with the structure. They have all these modules that cover everything. The modules don’t necessarily talk to each other. They’ll have standard reports for each one, but in managing a health system as a CEO and all the teams underneath you, you need very specific information relative to what you’re trying to accomplish.
In this particular example, right out of the gate, you need to know where to bring the patient. If you don’t have real-time visibility as to the capacity in terms of staff beds and alternative places for a patient to go, like a service line, ambulatory setting, or something where they could get good care, that might be higher quality and lower cost. If you don’t have visibility of that to a system upfront and near real-time, you may very well make a bad decision and get a patient in a bed that doesn’t belong there. It’s not the best setting of care, and it blocks somebody else.
You then have all of the incremental processes that go along with that. Gina talked about payor mix and payor mix clarity. Even going up earlier, as soon as they get in, what is that estimated date of discharge relative to that patient so you can plan for it? Is that then built into your multidisciplinary rounding? You have to account for patient choice.
How do you make sure that you get good responses, acceptance rates, speed to acceptance on your providers, and our requests going to viable post-acute care providers as opposed to a blast out to thousands of them that may not be relevant to what the particular patient needs? All of these are incremental steps and little milestones within a patient journey that have to be clarified.
The important data that needs to be associated with that, that’s insight, not just data. That is essentially what organizations like ABOUT can do with health systems. It’s to come in and help them extract that, identify what is the ideal path or process for the patient, and then provide the relevant insight to be able to make the best decision for the patient in a timely and high-quality way.
Gina, how do you get leaders to spend time with and understand the workflow processes and requirements that we’re talking about? Having been a CEO of a health system, the COO is very focused on the day-to-day operational processes, getting the trains on time, and those sorts of things. I’m not sure that they fully understand.
It’s like the IT department is in its own silo. The analytics people are in their own silos. How do you get some of these leaders to understand what has to be done so that they can help integrate some of these functions and processes that have been standalone into the actual workflow processes to get a patient to move through the system more smoothly?
In my experience as a leader in healthcare, it’s about tying what matters to those executives back to them. What matters right now to most executives in healthcare is staff retention, nursing specifically, and all the ancillary services, length of stay, avoidable days, and cost containment. You have to be able to bring it to them and show them in a way that will help them feel empowered to identify a couple of key interventions that they might target. Rather than trying to fix everything at once, let’s try to fix a couple of things that are going to have the biggest bang for the buck.
It all comes down to connecting the entire multidisciplinary team into one working unit that’s going in the same direction. It’s a lot of clarity around the next side of care, understanding that, and making sure that the right people are messaging that. Also, understanding that the next side of care impacts who can get care currently. That’s a personal thing to most clinicians.
We want to know that we’re doing the right thing for the sickest patients and the patients who need us. I believe you need to have that message from an executive team to understand and connect the financial and clinical outcomes. When a patient can’t leave the hospital, how does it affect those also that can’t get into your hospital so that they have that visibility and situational awareness?
Utilizing the multi-disciplinary rounds is a great tool to make sure that every single day on every unit, on every patient, that multidisciplinary team is discussing the estimated day of discharge. I like to talk about it in a way that’s what the plan is for the day, the plan for this day, and the plan for the way of discharge. If you keep that very simple moniker out there for the entire multidisciplinary team, they get into a cadence of thinking that way. That is ultimately going to affect those that you can try to get into your system.
Lastly, working with the data to present it in a visual way so that they see it in a system approach and they are going to be tackling those patients that are waiting to transfer in and identifying other hospitals in their system that they might be able to move those patients to at a different level of care. It’s not always waiting for the academic medical center or the key player in their system but saying, “We can provide this service somewhere else. Let’s get this to this patient and give them the choice to move there rather than waiting in an ER or waiting on a transfer list for a long period of time.”Identify other hospitals in your system where you might be able to move those patients to at a different level of care. Click To Tweet
You brought up multidisciplinary rounds and the importance there. This has been something that hospital systems have done for a long time. I worry and I’m curious as to your opinion on this. I believe it’s an effective tool. How do you help them get over the hump that, “We’ve tried this before, and it’s just another thing we got to do through the day that takes us out of seeing our patients are rounding?” so they can do it effectively and can make those forward movements on the day to stay in the way.
It has to have a complete leadership approach and they have to embrace it across all parts of the hospital, like physician leadership, nursing leadership, care management leadership, ancillary, physical therapy, and occupational therapy. This has to be something that is embraced by the top-down leadership and everyone going into them.
One thing that I’ve been successful with is having a checklist and making sure that the staff who are in the multidisciplinary round have a script or a checklist that they can go back to and make sure that they’re covering all the correct things. In addition to that, it’s having leaders throughout the organization appear at the multidisciplinary rounds on a consistent regular basis and bring a checklist with them and make sure, “Coaching in a moment. We didn’t talk about EDD with this patient. What’s the EDD?” It’s setting that tone as a leader that this is important and we have to know this in order to get to discharge.
I haven’t been a practitioner for quite a few years, so I haven’t been down in the emergency room as a physician. I’ve been in the emergency room many times as an administrator to see what the issues are. It seems to me that the same paradigm that we used when I was in the emergency room working years ago is the same paradigm we’re using now. Which is that somebody hits the emergency room, and they may not have needed even to come to the emergency room. It may have been much better for them to be directly admitted through the admitting office if they needed to be there.
The other issue is we have this automatic way of looking at things. Somebody comes to the emergency room, and they’re put in a bed. The first thing we’re thinking about is we need to find them a bed up on the floor. Maybe a bed up on the floor isn’t the most appropriate thing that they need right away. Maybe they need a procedure and could be sent directly to have the procedure done. Maybe they need something else other than a bed on the floor. Could you discuss that a little bit? It seems to me that’s a big issue, as well as the mental health crisis now also being a big issue. It’s the appropriate way of dealing with some of these things that don’t always mean looking for a med-surge bed.
I’m happy to dive into it. As you know, the priority for emergency departments is to triage, understand what the patient’s needs are, and then manage it through the disposition as to where they need to go. If they’re able to treat, release, and get them out, so much the better, but they need to keep them moving.
Often, ED physicians in a disposition, if they’re uncomfortable that the patient can safely go home, will ask their hospitalist colleagues to be able to admit them an OB status into a unit, which compromises the capacity of the organization. It’s not unusual that those patients don’t meet the medical necessity criteria for admission.
Hospitals have been trying to prevent that by putting case management resources in the ED to have that exchange with the ED physicians. ED physicians don’t often like that because they want to be able to function independently and move patients through. It’s a conundrum for health systems. It also has become more complicated because of the expansion of the various settings of care.
Could they go to hospital-at-home and have some supervision? Is home health appropriate for a little bit more support? Is there some kind of an ambulatory environment where they can go on a transition? All those kinds of things typically are not known by the ED staff. They’re just trying to get the patient in and out.
What we have identified is that what used to be the traditional command center function needs to move to the front of the hospital from an access center standpoint. It’s still a command center, but it’s looking to answer those questions. Some of our clients are finding that if the ED is requesting that from the access center, they have the visibility to see everything that would be potentially best for that patient and intervene on behalf of the ED to be able to get those patients’ place.
Switching quickly to your question about behavioral health, behavioral health is a thing unto itself, as you all know. I happen to have a son who has schizophrenia. I’ve been dealing with this as a parent as well for a long time. What I’ve learned is there are a lot of community-based resources that need to be identified and tie-in hospital-based emergency departments to better manage it.
Once the patient is triaged, being able to get them into these community resources requires coordination and time. They’re out there in most communities, and it can be a much better experience for the patient and family if they do that once the patient is stabilized. In all cases, the underlying themes are to get a plan, be able to see and have visibility to what’s available, and then make the best decision for the patient in the most expedited fashion. Everyone benefits from that, including the ED providers who are able to then much more efficiently manage their patients.
Let me go back to something that Gina said and touch on this for a minute. I know we’ll be covering this for the full show coming up over the next couple of times. This whole idea of an access center or a command center strikes me that as old as the FAA’s computer system is and as decrepit as the entire air traffic control system is. Somehow they manage to know where every plane is. Somehow they manage to get all of the planes coming in. I fly in and out of Atlanta a lot. You look out the window, and you see planes on both sides of you. They get them spaced appropriately. They know when the plane should leave wherever it’s coming from to come in. They don’t put three planes at a gate if they run out of the gate. They have all this figured out.
Gina said something earlier about, “What about putting the key individuals who control all of this motion into one place?” I know when people think about command centers, they think about millions of monitors, millions of dollars again, and all sorts of things. I know in a past life, you and I worked together where we did this without all of that fancy hardware and equipment. We ended up cutting the length of stay down by 3/4 of a day in a fairly short period of time.
Maybe you could comment specifically about some examples that you’ve seen where this has happened and talk a little bit about how you can do this in a very practical way so our audience can then walk away with some ideas about exactly how they might do this and who should be in this room understanding where all of the flow is occurring.
The criticality of a command center is that the resources that are necessary to manage those details are aligned. In the FAA airport example, it’s gate agents, pilots, and the staffing for pilots. As long as those resources are coordinated through the command center or in collaboration with it, it works. If they weren’t, it’s a disaster. It’s similar to the health system.
If your house supervisors, unit-based resources, and on-call providers are not aligned and able to take patients coming in, it falls apart. It’s not just about having a bunch of pretty dashboards. That might be impressive to a guest, but the reality is how you’re operating on the frontline in terms of coordinated resources. We use a number of tools like secure messaging, where all of these critical resources are connected and able to, without any phone call, interact. We use a setup of on-call provider coordination upfront.
There’s a preexisting expectation when you get a request and how you’re going to respond. When those pieces are in place, then the access at the command center can be capable. If they’re not, it’s basically checking the box to say, “We have a command center.” There’s no demonstrable change and results without that tightly interconnected number of resources that are getting the job done.
I will add on one of the challenging areas that we haven’t talked about. It’s the lack of EMTs. Getting a patient simply transported out of the hospital or into the hospital is now a new set of challenges we hadn’t experienced a few years ago. Some of the successful clients have put somebody into their command center, who’s in charge of quarterbacking, where are the patient, who’s going to get the ambulance at what time, and making sure that those ambulances are utilized appropriately.
Getting patients out to a post-acute provider and also bringing them in, that quarterback sitting in the command centers is deciding when, where, who, and how that’s going to happen. That can be very successful when they’re shifting them around. When patients who had an ambulance scheduled to pick them up and discharge them no longer need it, they can use that same ambulance for another patient. That makes it much more visible.
First of all, it’s great that we get time to rubber-meets-the-road end here. As far as leaders, organizations, healthcare systems, and hospitals are concerned, I know they’re looking for these answers, and I’d love to talk to them. I’ve talked with organizational leaders around the country over the past several years. I find that they’re brilliantly thinking about what their organizations need to do to succeed, but oftentimes they’re stifled and stymied by the juggernaut of the customs and traditions of their organization. It’s hard to break outside of that box.
The great starting place in all of this is what we call the assessment. You bring somebody in who’s very knowledgeable about the industry and who’s seen this done at a lot of different places. You get the assessment of your organization from a skilled consulting group like ABOUT. ABOUT then compares that to those great successes that have happened at other places, and now you see the delta.
From there, you can start progressing forward by saying, “What are we going to break from as far as traditions are concerned that we know will be effective in moving flow through better in accommodating and creating better accessibility?” Quite frankly, leveraging many of the resources that we already have in place is a better way to get to the success metrics we’re looking for. It all begins with the assessment.
Thank you, Darin. Gina, it’s been great having you. Thank you so much for all of your insights and practical information that you were able to give. This is a problem that doesn’t seem to have gotten very far down the road toward a solution in many years. Every health system is finding this to be probably one of the most important challenges that they need to overcome if we’re going to be able to see more patients, increase our revenues, and take better care of people. It’s got clinical, financial, operational, and technological issues associated with it. It somehow has to all be brought together in order to find the right solution.
Thank you all very much. Ben, I’m going to turn it back over to you. I know that over the next few shows, we’re going to continue our guests that sit in the chair and do the actual work to try to enlighten our audience on some of these real basic operational issues that people are facing. Do you want to tell us a little bit about the future and what’s going to be happening on our show?
The next episodes are about creating and managing a care network. We hope to be able to have a chief nursing officer who is directly dealing with that in place for that discussion. Next, we’re going to be talking about tracking and comparing performance. That will lead up to the next webinar on April 25, 2023, with the title of Barriers and Solutions to Patient Input.
To your point, Chuck, these are all really practical issues that health systems have been trying to deal with for a long time. Now with new technology, approaches, and ways to be able to create meaningful insight that is data rich, insight poor, and trying to change that over to provide insight-rich is where we’re going with this.
Thanks to everybody. Thanks to our audience for reading. We’ll look forward to hearing from you on the next show. Take care, everybody.
Bye. Thank you.
About Gina Kidder
Gina became an RN after working on EMR implementations for Shared Medical Systems (SMS), and worked as a Trauma Nurse Clinician for a Level 1 Trauma Team in suburban Chicago. While completing an MSN, Gina transitioned to Care Management leading nurses and social workers in academic and community hospital settings prior to the challenging pandemic starting in 2019, and throughout. Gina is certified in Care Management through ACMA and an active member of the Illinois Chapter of ACMA.