C O L L A B O R A T I V E C A SE M A N A G E M EN T

Opening the Door to Timely and Informative Discharge

By Howard G. Dubin, MD, FCCP, FCCM, FHM; Nancy Jubinville, RN, BSN, MS, ACM; Joanne Roy, RN, PhD

Every case management department should strive towards an efficient and effective patient discharge process without compromising
patient safety and quality. The positive outcomes supported by achieving this goal include a decreased length of stay (LOS), increased
patient satisfaction with the discharge process and improved revenue cycle by increasing bed capacity.

In October 2008 in an effort to achieve such outcomes,

MidState Medical Center in Meriden, CT, implemented a
CMA-LOS Yearly Comparison
redesign initiative known as Discharge Status Update (DSU) CMA-LOS 2008: 4.073    CMA-LOS 2009: 3.727
rounds. The goal of DSU rounds is to proactively identify and
eliminate discharge barriers for a safe, effective and timely
patient discharge experience. OCT 7

The Process
The case management team on each nursing unit at MidState
NOV 8
Medical Center is comprised of a nurse case manager and a social
worker. The focus of the case management department is to
identify and address discharge barriers that may cause prolonged
hospitalization. Because discharge planning begins at the point DEC 7
of admission and continues until the patient is discharged, the
discharge plan is shared with all disciplines, and a team approach
is required to successfully manage these transitions. JAN 9
The nurse case manager in DSU rounds is considered the
“quarterback” of the team. This individual directs the discussion
of the patient’s care trajectory and outcomes during rounds and FEB 8
ensures the plan of care is on track, preventing delays and identifying
potential issues to the appropriate discipline, in order to avoid
extended LOS. The nurse case manager begins rounds by
MAR 9
communicating to the team the assigned goal length of stay (GLOS)
referenced by the patient’s admitting diagnosis and documenting
in the electronic medical record (EMR). During DSU rounds,
barriers and potential barriers are identified and short-term goals APR 8
are established through discussion with the DSU team members.
These goals are then communicated to the appropriate disciplines
to facilitate care in the most efficient manner. MAY 9
During DSU rounds, the nurse case manager and the team
identify daily goals and any barriers affecting discharge. The case
manager documents the barriers and goals set during rounds in the JUN 8
EMR. The patient’s nurse confirms the goals that were established
during DSU rounds and he or she responds to each of the goals by
documenting whether or not they were met. If the goal(s) was not
JUL 9
met, the reason why it was not met is documented. This process
opens the lines of communication between all shifts caring for the
patient and allows the entire team to remain informed as to the
expected LOS and the goals that will allow a patient to progress AUG 9
until discharge.
A core team is identified to participate in DSU rounds based on
3 3.2 3.4 3.6 3.8 4 4.2 4.4
the specific needs of the patients on each unit. This team includes
the nurse case manager, social worker, nurse manager, advanced Figure A

continued on page 3

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 w w w . a c m a w e b . o r g

Opening the Door to Timely and Informative Discharge (continued from page 2)

practice nurse (APRN) and the nurse caring for the patient.
Realized gains in top box scores Specialty nursing units have identified other disciplines to be
included in DSU rounds, such as dietary or pharmacy personnel
for Discharge Satisfaction
if the need was common to the majority of their patients. For
on pilot units example, oncology includes dietary and pharmacy professionals.
DSU rounds focus on the identification of barriers to discharge
and should not be confused with clinical team rounds, which
’08 TOP BOX SCORE
58% primarily focus on clinical care details. Extensive clinical
’09 TOP BOX SCORE
conversations are held following DSU rounds.
56% During DSU rounds, the leader summarizes the next steps and
accountabilities toward eliminating barriers in order to progress
54% the patient toward a safe and timely discharge. A typical scripting of
DSU rounds may include:
PERCENT TOP BOX

52% Case Manager: Ms. Q, admit 1 day ago with CHF, decreased
O2sats. Patient is receiving IV Lasix 40 bid, O2 @ 2 liters.
50% Goal LOS is 3 days with expected discharge date on
Thursday. Is patient going to meet this goal?
48% Nurse: Lung sounds are improved. She is still receiving IV Lasix.
APRN: We will start to wean Lasix. Will wean 02 as well. If she
46% progresses as expected she should be able to be discharged
by Thursday.
44% Social Worker: Patient has a supportive daughter who lives next
door. Social worker anticipates the patient will need home
care services on discharge.
UNIT EXTENT FELT
READY
SPEED OF
DISCHARGE
INSTRUCTION
CARE AT HOME
Case Manager: Short term goals for today: Wean O2, wean
1 DISCHARGE PROCESS Lasix, out of bed ambulating, obtain O2 sats while
ambulating, CHF education, refer to home care agency.

’08 TOP BOX SCORE

54% Goals and Outcomes
’09 TOP BOX SCORE
The goals of DSU rounds at MidState Medical Center are to:
52%
• Decrease patient length of stay without compromising
patient safety and quality (see figure A).
50%
• Increase bed capacity
PERCENT TOP BOX

48% • Increase patient satisfaction with the discharge process

(see figure B).
46%
Following the implementation of DSU rounds, the organization’s
44% case mix adjusted length of stay (CMALOS) improved by 8.2%. This
reduction accounted for 5352.85 days per year with a potential
42% additional case volume of 1436.236 or an additional 3.93 virtual
beds per day. The risk adjusted mortality rate also decreased by
40% 13.45% from 0.11566 in 2008 to 0.10620 in 2009. Patient satisfaction
scores related to the discharge process also improved following the
implementation of DSU rounds.
UNIT EXTENT FELT
READY
SPEED OF
DISCHARGE
INSTRUCTION
CARE AT HOME
DSU rounds have also established a culture of accountability
2 DISCHARGE PROCESS
at MidState Medical Center. Each team member has clearly defined
role expectations and outlined contributions in order to meet the
Figure B needs of the patient.

continued on page 4

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Opening the Door to Timely and Informative Discharge (continued from page 3)

Conclusion
The DSU process fosters a communication-rich culture,
augmenting an efficient and informative discharge for patients and
their families through effective communication and documentation.
The challenge to reduce LOS and maintain patient satisfaction
and quality care, while remaining continually prepared for changes
in health care and regulatory requirements, is ongoing. Case
management leaders must always evaluate and address the
principal cause of delays and unnecessary reasons for extended
hospitalizations. At MidState Medical Center, DSU rounds help
to recognize such issues. Nurses and social work case managers
will continue to be the leaders in the DSU process by collaborating
with health care team members to identify and intervene with
issues causing delays and extended hospital stays. They coordinate
the team to ensure that patients receive the right care, in the right
place, at the right time.
Nancy Jubinville, RN, BSN, MS, ACM, has been the Director of
Care Management at Midstate Medical Center since April 2009.
She earned her undergraduate degree from Assumption College
in Worcester, MA and her graduate degree from University of
Connecticut. During her career she has been involved in case
management for more than 20 years, both in the insurance (HMO)
industry and in the acute care hospital setting.
Joanne Roy, RN, PhD, has been the Director of Clinical Professional
Development at MidState Medical Center for 2 years. She earned
her PhD in Nursing from the University of Rhode Island, earned her
MSN from University of Connecticut and her BSN from Western
Connecticut State University. During her career, she has 30 years of
experience in acute care medical surgical nursing, nursing education
and academic faculty affiliations in undergraduate and graduate
schools of nursing.

Howard G. Dubin, MD, FCCP, FCCM, FHM, has been the Medical Endnotes
Director of the Inpatient Hospitalist Program at MidState Medical Figure A: Executive Dashboard TSI
Center for the past 4 years. He earned his MD from the University of
Figure B: MidState Press-Ganey Survey results: 2008 11/07–10/08;
Massachusetts Medical School and has trained in residencies and 2009 11/08 – 8/09
fellowships from Brown University and University of Pittsburgh
Medical Programs. During his career he has over 30 years of
experience in acute clinical care, medical informatics and medical
management models.

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