Patient Flow Janet Gillen, LCSW Director of Social Services - - PowerPoint PPT Presentation

Patient Flow

Janet Gillen, LCSW Director of Social Services

Patient Flow Coordinators: Debbie Tam, RN Ghodsi Davary, RN May 27, 2014

Recent Years of Pivotal Change for Long- Term Care Community

• Community providers experiencing the loss of 300+ Laguna

Honda beds and closure of other community SNF beds in an aging population - ongoing pressure from hospitals and community for LHH beds

• DPH Strategic Goal of Integration and appropriate level of

care resulting in improved Patient Flow

• Successful closure of the Chambers class action lawsuit and

its focus on community re-integration and wrap-around services

• Implementation of ACA-San Francisco Health Network and

its Managed Care system

Operational Changes

• Staff and resident/family education and participation in transitioning the residents to

their appropriate level of care

• Education to referring Hospital Discharge Planners on Lower Level of Care options
• Using Data Measures to quantitatively measure goal progress
• Increasing bed utilization and turnover
• Decreasing wait time for admission
• Creation of 15 bed Discharge Household on N3
• LHH accepts weekend admissions
• LHH Social Services shares access to the Placement Referral Tracking System
• LHH Patient Flow Coordinator integrated into SFGH discharge meetings and

monitors census, admissions and discharges daily

Staff Education and Participation

• Ninety-five percent completion of Healthstream Module on

Appropriate Level of Care

• Revision of language in the Conditions of Admission and

Laguna Honda Rules and Responsibilities

• All Resident Care Teams attended a DCIP (Diversion

Community Integration Program) meeting

• Social Services Department held 4 Discharge Fairs a year

for residents, families and staff on discharge resources

Data Measures

• Monthly Census reports developed and available for managers for

review

• Ongoing review of resident appropriate level of care data measures
• High level Dashboard utilized by San Francisco Health Network

leadership to monitor patient flow

• LHH Classification of Discharge Barriers is in process now that will

be populated by Social Services and Quality Management

• Monitoring outcome of discharges

New Admissions & Community Discharges: Q1 2011 – Q1 2014

Internal Changes: Micro level

• Weekly Discharge Huddles on each neighborhood
• QM and Rehab assigned a representative to every discharge

huddle

• Discharge Resource icon on the Intranet
• Admission and Screening Committee to meet twice a week

and as needed, to increase internal efficiency

• Monthly Behavioral Placement Rounds
• Clinical Leadership Rounds
• Involved Activity Therapy and Pharmacy Departments

Internal Changes: Macro level

• Regular meetings with Placement Team and Housing Partners to review

residents on wait-list

• Partnered with IHSS to do “Early Track” training
• Partnering with CBHS for SATS, Psych staff, Nursing Managers and Social

Workers

• Increased family and conservator attendance at Resident Care Conferences
• Medical Respite tour for Exec Team
• Growing the respite program
• Increasing our use of 2-3 day trials at home
• Successfully transitioned 11 Behavioral Health Center clients in 2012 and 12

clients in 2013 to LHH. Repatriated 6 locked facility residents from out-of- county to LHH.

Results Thus Far

• Our average wait time for admissions from 12/1/12 to

12/31/13 was 3.91 days down

• Discharges have increased for 2013 (252) from 2012

(185) and numbers look good for 2014

• Increased SNF beds from 765 to 769 capacity
• Number of patients served from 2012 to 2013 was

1,191.

Future Challenges

• Remaining viable and thriving in managed care

environment

• San Francisco Health Network: Can LHH residents

discharge in less than 60 days?