Improving discharge planning to reduce length of stay and readmissions

The lack of a consistent and effective discharge planning process is a significant impediment for Australian hospitals looking to maximise patient access. In many cases, this is a symptom of the poor visibility clinicians and staff have of their patient’s progress throughout their stay in the hospital – especially due to the many disparate systems and manual processes that are used to manage the planning for patient discharge.

For example, when Allied Health referrals are made via telephone or on a paper-based form, Allied Health staff have no visibility of how long the patient has been in the hospital, or what else the patient is waiting on for discharge. As a result, these Allied Health staff are unable to prioritise patients with respect to the patients expected discharge date, resulting in patients unnecessarily remaining in beds beyond the expected length of stay (LOS), waiting for an Allied Health assessment.

This is just one in a range of instances (such as pharmacy, pathology, radiology, clinician visits) in which insufficient visibility of a patient’s status towards discharge impacts hospital efficiency.

To gain a broader understanding of its impact, I spoke to Janice Osteraas, Patient Access and Demand Manager, Bendigo Health on the recent discharge planning advances she has been leading.

When Janice first began advocating for change, Bendigo Health was dealing with many of the same issues I’ve discussed above around insufficient visibility of patient status while planning discharge. Specifically, Janice and her team were troubled by:

  • High unplanned readmission rates. At the time, Bendigo Health’s rated around 5.5%. While this was still not high against national averages, Bendigo Health felt there was room for improvement which would result in better patient outcomes.
  • The inability to easily identify, track, and prioritise complex patients. This was a significant issue due the various services charged with the care of such patients, and the lack of assigned responsibility towards ensuring their efficient discharge.
  • High unnecessary bed days with some patients staying beyond the average State LOS, resulting in avoidable reductions to hospital revenue, but with little reduction to cost.
  • Complications resulting from prolonged hospital stays. Patients are more likely to become unwell the longer their hospital stay.
  • Reduced patient access. With patients staying past their expected LOS and some being readmitted, the potential capacity of the hospital is reduced.

The first step towards solving these problems was to identify what Bendigo Health needed to address them most fully. Together, Janice and the Patient Flow Performance sub-committee – a multi-disciplinary stream (acute, sub-acute, psychiatry and ambulatory) committee that defines and agrees on expectations relating to patient flow, including improving discharge planning – determined that it was necessary to ensure:

  • Visibility of each patient’s status towards discharge;
  • A single source of truth to capture and access all patient status information;
  • The development of key performance indicators of when a referral should be sent and when a referral should be acted upon; and
  • Clearly defined discharge processes that were consistent across the various services, and agreed upon by all stakeholders.

Janice reflects, “What we needed was a shift in how we approached patient care. From the moment a patient was admitted, we needed to be working towards discharging as soon as it was clinically appropriate, and as safely and efficiently as possible.

At the time, Bendigo Health was already using Health IQ’s Patient Flow Manager (PFM) to achieve increased visibility for bed management and capacity planning. Janice saw the opportunity to build on PFM’s existing functionality to achieve the required increased visibility around patient status and also provide the portal for the capture and access around this information.

As a result, we worked together to develop this new configuration of Patient Flow Manager: Discharge Planning, to provide:

  • Real-time visibility of individual patients’ status towards discharge;
  • A single source of truth to all associated information;
  • The ability to track, identify, and prioritise patients based on special circumstances, i.e.: complex patients;
  • The ability to hold staff accountable to their responsibilities and KPIs;
  • The ability to measure the efficiencies of key processes, i.e.: time from referral made to referral actioned; and
  • Specific views that are customised to the role that would use them, i.e.: pharmacy would only need a snapshot view of all awaiting scripts, prioritised by patients with impending discharge.

Patient Flow Manager has given us a consistent platform for discharge planning across the organisation. We take the attitude of, ‘If it’s not in Patient Flow Manager, it hasn’t happened,” says Janice. “It’s designed to support our processes, and gives us the visibility to ensure that they’re being followed.”

Of course, visibility without good processes and genuine staff engagement will just show you a whole lot of things that you don’t want to see. That’s why the commitment of the staff of Bendigo Health to the new processes, rules, and KPIs that have been implemented is so important.

12 months following the implementation of ‘Discharge Planning’, which Bendigo Health refer to as the ‘Ticket Home’, Janice has seen discharge planning undergo a true transformation:

  • Readmission rates have reduced by an incredible 30% from 5.5% to just under 4%.
  • Specifically for complex patients, readmission rates have reduced by 50%.
  • Over five years Bendigo Health’s acute separations (discharges) have increased by 17% with ED presentations increasing by 11%, however, the  multiday LOS has decreased by 0.53 of a day since this process was implemented.
  • This has not only resulted in reduced risk of long-stay complications, but helps bring the health service’s revenue per patient closer to optimum.
  • Patient access has improved, as more patients are going home on time, and beds are being used more efficiently.

We at Health IQ are extremely proud to have played a role in helping Bendigo Health in improving discharge planning at their hospital.

If you are experiencing any of the issues I’ve described above and would like to discuss, or if you’re keen to learn more about the experiences of Bendigo Health with Patient Flow Manager, please call me on 03 9425 8012 or send me an email to

Janice Osteraas is the Access and Demand Manager at Bendigo Health, and is responsible for developing, implementing, and evaluating the annual Patient Access and Demand plan, working with executive and other relevant stakeholders. She has worked at Bendigo Health for more than 14 years and holds Master’s degrees in Business Administration and Nursing.

 Dave Piggott is the Executive Director of Health IQ, and is focused on helping Australian health services achieve better visibility and communication within and across their hospitals. Dave has over 20 years’ experience in Health IT. A graduate of the Australian Institute of Company Directors (AICD) and with a Masters in Open Systems (IT), Dave has worked extensively in the Patient Flow area, and helped over 30 Australian hospitals to improve their flow of patients.

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