Evaluating and Streamlining an Urban Academic Medical Center’s Hospice Referral and Discharge Process

From the 2023 HVPA National Conference

Margaret Krasne MD MPH (Division of Hospital Medicine, Department of Medicine, Johns Hopkins Hospital), Elys Bhatia MSCS (JHHS Quality and Clinical Analytics), Allyson Mitchell LCSW-C, Michelle Churchill MSN CRNP ACHPN, Catherine Boyne MHA, Danielle Doberman MD MPH HMDC FAAHPM

The average lead time from placement of a hospice referral order to hospital discharge with hospice services at the Johns Hopkins Hospital (JHH) is over three days, with one in six referred patients not enrolling in hospice because they die prior to discharge. Prolonged time to discharge can be detrimental to this vulnerable patient population, who spend their final hours and days in the hospital and sometimes miss a safe window for discharge to their ideal location. Delayed discharges are also detrimental to the health system, increasing length of stay, decreasing hospital capacity, and increasing in-hospital mortality. We sought to develop a workgroup to evaluate the hospice referral and discharge process at Johns Hopkins Hospital, identify key drivers of delays, and implement interventions to address these factors to ensure patients are discharged efficiently with optimal services.

We extracted electronic health record (EHR) time stamps, including those for a hospice referral order and discharge time, to evaluate JHH’s mean lead time (hours) from placement of a hospice referral order to patient hospital discharge on all hospital units. We focused our evaluation on two general medicine units and developed a multidisciplinary workgroup based in these units with representation from case management, home care, palliative care, primary teams, and social work. Using lean sigma principles, we performed a comprehensive analysis of the current hospice referral and discharge process on these units. We evaluated the current workflow and involved parties, performed root cause analysis, and identified key drivers of delays. Based on these findings, we implemented an intervention to address key drivers. Our work required close partnership with hospital leadership in care management, home care coordination, and palliative medicine.

From 9/2021 through 2/2023, 57 patients on two general medicine units were discharged to an inpatient hospice unit or home with hospice services. Mean lead time from hospice referral to discharge was 92 hours. Process mapping (Figure 1) revealed the complexity of the referral and discharge process, involving the coordination of up to five different teams to complete many steps. Identified key drivers include lack of clarity around hospice level of care, lack of shared knowledge around medical capabilities of specific hospice agencies, and many multi-disciplinary team members requiring significant coordination efforts.

The workgroup identified potential interventions based on the key drivers. Notably, while hospice agencies determine level of care (i.e. home or general inpatient (GIP) care), the hospice referral process was split between care management and home care coordination based on the medical team’s presumed level of care. In this setting, we enacted an intervention to streamline the referral process, whereby care management would perform all hospice referrals and home care coordination would remove themselves from this step. The intervention launched in early 3/2023, with two hospice discharges in our first month (Figure 2) and data collection ongoing.

It is essential for both patients and the health system for the hospice referral and discharge process to be accurate, efficient, and effective. Our evaluation has identified potential areas for intervention, and we have launched a pilot seeking to streamline the overall process and individuals involved, with ongoing data collection and positive frontline feedback thus far. We plan to continue to engage with hospital leadership and consider other interventions for further optimization.

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