From the 2024 HVPA National Conference
Ada Offurum MD (University of Maryland Medical Center, Downtown Campus), Sneha Tella MD (University of Maryland Baltimore Washington Medical Center)
Background:
Studies have shown that patients who remain hospitalized while awaiting discharge to a skilled nursing facility, are at a higher risk of hospital acquired conditions and worsening physical deconditioning. These patients do not receive the high intensity rehabilitative services which they would have received in a skilled nursing/rehabilitation facility (SNF). These delays in discharges are recorded and tracked by hospitals as avoidable days. In addition to adverse events, avoidable days also lead to revenue loss from insurance denials, poor throughput, increased administrative burden and lower patient satisfaction.
National benchmarks have demonstrated that patients being discharged to SNFs account for a significant percentage of in-hospital avoidable days. These delays in discharge to SNFs can be due to increasingly complex patients with difficult social issues, limited SNF bed availability and staffing, transportation barriers but mainly from delayed preauthorization.
Hospitals must receive authorization from patients’ insurance companies (payors) to use their SNF benefits, before transfer. The preauthorization process can be lengthy via the traditional model in which hospitals submit paperwork to the SNF and the SNF sends the paperwork to the payor for authorization.
Most institutions in our large hospital system recorded an average of 4.5-6 business days between when the patient is medically ready for transfer to the SNF setting and when authorization is approved.
Objective:
To reduce patient delays related to prolonged SNF authorization process by
A. Shifting the ownership of the SNF authorization submission from the SNF to the hospital
B. Implementing innovative staffing strategies with the use of case management assistants to supplement the expanded responsibilities associated with internalizing the authorization process
Methods:
At our University of Maryland Baltimore Washington Medical Center campus, we established that the turnaround time for SNF authorization averaged 4.35 days.
Initially, a pilot of 6 cases was conducted to ensure that it was feasible for the hospital to obtain authorization without the SNF as the go-between.
Average time to get authorization in the pilot was 0.6 days (from 4.35) with patients being able to be discharged shortly after. Based on the success of the pilot, the new process was approved by hospital leadership for all patients.
Results
In 2022
Total submitted authorizations= 520
Total approved authorizations= 439
Average time to get authorization= 0.974 days (from 4.35 days. Reduction of 78%)
Avoidable Days Saved= 439 days
Estimated financial impact = $660,695
Case management assistants were successfully hired and trained to execute and facilitate the preauthorization process with the payors.
Clinical Implications
Hospitals submitting SNF authorization internally decrease redundancies, thereby reducing wait time for patients to transfer to the next level of care. This decrease in overall inpatient LOS leads to:
Reduced risk of hospital acquired infections such as urinary tract infections and non-infectious complications such as falls, delirium, venous thromboembolic events for the patients awaiting transfer.
Reduced physical deconditioning from inability to receive intensive physical and occupational therapy while hospitalized in an inpatient unit/bed.
Decreased frustration and anxiety of the patient and reducing patients’ frustration over delays in transfer.
Increased bed availability on the inpatient units which improves patient flow and reduces prolonged emergency room boarding which has been associated with adverse patient safety events.
Conclusions:
The remarkable success of internalizing the authorization process at our system community hospital has led to system wide leadership buy-in and is being adopted across UMMS hospitals.