Transitioning high-risk patients: Tactics for creating capacity

Managing high-risk patient transitions after discharge from the hospital is a growing challenge, especially with workforce shortages and capacity constraints. And a growing senior population combined with more adults living with chronic illness increasingly necessitates more — and better — post-acute services.

“Transitions from hospital to post-acute care is both time consuming and complex. For example, when discharge tasks such as exercise oximetry tests are not coordinated and stack up on the patient’s last day, any disruption can cause a cascade of negative events such as delays in discharge, post-acute treatments and subsequent readmissions,” said Margaret Rudisill, performance improvement senior director at Vizient. “In fact, up to 30% of all hospital admissions have a 24-hour discharge delay due to nonclinical reasons.”

As part of ongoing work to address hospital capacity constraints, the Vizient Member Networks Performance Improvement Programs recently focused on these patients and completed a collaborative Creating Capacity: Transitioning of High-Risk Patients Collaborative with 39 member organizations. They focused on the top 2% of their utilizers, marrying data from the Vizient Clinical Data Base with the Vizient Vulnerability Index™ to identify which social determinants of health (SDOH) these patients struggle with.

“We know that SDOH such as housing instability, food insecurity, transportation barriers and limited access to educational opportunities and employment significantly influence individuals’ health outcomes,” said Heather Blonsky, lead data scientist at Vizient. “By screening for these factors, healthcare providers can gain a more comprehensive understanding of patients' lives beyond their medical conditions. This holistic approach allows for tailored interventions that address the root causes of health disparities.”

The six-month collaborative that began in 2024 — one of four collaboratives focused on capacity in the last two years — engaged the healthcare organizations to implement leading practices, such as creating specialized care teams and addressing SDOH, which collectively resulted in a 4.7% reduction in mean length of stay (LOS), avoidance of 198,000 inpatient days and $317 million in annualized costs.

Identifying those at risk

One collaborative participant, a 600-bed academic medical center with a specialized oncology unit located in the Northeast, focused on reducing LOS for oncology patients. Incorporating the Vizient Vulnerability Index™, they created a novel LOS predictor tool to identify hematologic oncology patients at risk for prolonged days.

By leveraging the Vizient Clinical Data Base LOS methodology and Observed/Expected index, they achieved a reduction in LOS from 1.27 to 0.97 following implementation of strategies to better identify and manage these high-risk patients. Strategies included, streamlined admissions and a transition care team that bridged coordinated patient care such as the use of American Cancer Society housing for patients in need and standardized care pathways through discharge and beyond. In fact, using interdisciplinary rounds, medication reconciliation and expanded home health options, they achieved an 85% discharge home health rate.

“The sooner healthcare organizations identify and screen for SDOH as part of identifying patient needs, the sooner they can provide more coordinated care that impacts the chronic disease prevalence of patients, their behavioral health and overall life expectancy,” Rudisill said.

Palliative care

Palliative care that focuses on relieving symptoms and improving quality of life for both the patient and their family is an important but often overlooked service. One participating academic health system in the Midwest began work with an external hospice agency to enable their in-house palliative care team to provide services to more patients. They also changed workflows to support early intervention for patients with known severe illness.

Other successful strategies by several organizations included enlisting key palliative care champions, providing education to all providers about palliative care and what constitutes a patient’s eligibility for a consultation, and providing palliative care consultations within 24 hours of a patient’s arrival, which may occur in the ED.

“Those patients who are screened for palliative care services on hospital day one are more likely to improve and have a shorter length of stay overall,” Rudisill said. “Additionally palliative care teams maximize hospital efficiency and lower costs.”

Dedicated post-acute care champion

Transitions from one care setting to another or to the home are one of the most vulnerable times for patients. They are more likely to experience adverse events that lead to poor outcomes, which in turn result in significant financial losses for healthcare organizations. Additionally, a myriad of other factors can delay timely discharges. For example, finding available skilled nursing facilities, insurance authorizations and family decision-making around choice contribute to over 80% in excess days.

However, many of the collaborative participants shared successes amplified by a dedicated professional such as a post-acute care liaison, transition specialist and/or discharge navigator in their organizations. They’re able to collaborate with care delivery teams to enhance patient access to providers, promote home health services, and serve as a liaison between the health system and acute care organizations to establish shared goals for post-acute care utilization.

“Complex patients require the care of complex teams,” Rudisill said. “These liaisons are important members of a coordinated team — including physicians, nurses, geriatricians, social workers and palliative care representatives — and are crucial for creating post-acute relationships and resources to ensure a smooth discharge for those patients transitioning to post-acute care and those who are going home.”