Leveraging an internal and external inter-professional team for the most complex discharge solutions

From the 2022 HVPA National Conference

Ada Offurum MD (University of Maryland Medical Center), Nidhi Goel MD


In 2014, our tertiary care academic center had a small group of providers, case managers, and social workers who would elevate the cases of patients with prolonged length of stay or high resource utilization. This group had significant limitations and an inconsistent workflow. As a result, we devised the Discharge Focus Group (DFG): a multi-disciplinary,  group with partners from within and outside of our institution with the shared goal of transitioning patients safely from the acute to the post-acute setting, no matter how complex their needs. The group and the role of each person within it has evolved and solidified, leading to more innovation and improved patient throughput.


Identify and assemble a team of key internal and external interdisciplinary partners to collaborate with, based on the needs of our patient population and available community resources, during precarious discharges.

Create a process for care providers, physician advisors, and case management teams to proactively identify patients with complex discharge issues.


Core internal DFG members include physician advisors, case managers, social workers, utilization management specialists, and physical/occupational therapy.  Additionally, we have the participation of community partners, including liaisons from all major area skilled nursing facilities and navigators for local assisted living facilities.  We also recognized the need to have “as needed” participation of various other experts, including clinical pharmacists, ethicists, legal counsel, and risk managers. Weekly DFG cases are pre-screened for the ‘as needed’  experts to participate when particular scenarios arise.  A pivotal member of the group is the program manager, who coordinates referrals to DFG, ensures the attendance of all required parties, and disseminates critical action items to the group. Updates are disseminated to local care teams afterwards.


Unadjusted Readmission rate
15.6  in 2015 (Before DFG)/14.5  in 2016 (start of DFG)/14.2 in 2017 (full DFG  implementation)Vizient ALOS index

1.01 in 2015 (Before DFG)/ 1.13 (start of DFG)/0.95 in 2017 (full DFG implementation)
Clinical implications of DFG.

Increased bed capacity by decreasing LOS: Limited bed capacity as a result of the staffing crisis and increased volumes from earlier stages of the COVID pandemic impacted the ability of front line staff to provide effective, high quality care to COVID and non-COVID patients. DFG provides a process to reduce patient days from extended custodial hospitalization and increased bed capacity for acutely ill patients.Decreased readmissions and associated adverse events: By reducing readmissions in the high risk complex discharges, DFG helps to mitigate post-discharge adverse events that would have occurred with a readmission including PCP follow up for test results, medication management

Reduce clinical decline associated with extended hospitalization: Extended custodial hospitalizations are associated with higher risk of falls, delirium, psychosis, worsening deconditioning and cognitive decline.  
Reduce anxiety and depressive symptoms in front line staff:  Providers and nursing staff have reported low morale, anxiety and depressive symptoms associated with caring for these patients. This can stem from physical violence from patients to care providers, ethical dilemmas when caring for reluctant guardianship patients, anxiety over measures taken to prevent elopement. 


DFG has shown appropriate return on investment through readmission and LOS reduction, cost savings from contracted payments to post-acute settings and provider satisfaction from situational awareness. It has become embedded in case management, social work and Physician Advisor workflow for escalations. We continue to work on referrals directly from providers.

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