NYC Health + Hospitals Develops New Way to Manage Hard-to-Discharge Patients and Prevent Unnecessary, Extended Hospital Stay

Pilot Program Addresses Intractable National Problem: Improves Quality of Life of Long-Stay Hospital Patients, Reduces Health Care Costs

Jan 12, 2017

Manhattan, NY

The NYC Health + Hospitals today announced a new pilot program that is improving the quality of life of long-term hospital patients who are difficult to discharge into post-acute care settings and is helping the health system save millions in costly and unnecessary hospital stays. Through the program, patients transition out of the hospital and into post-acute settings better suited to provide the care they need.

The “Better Way to Live” program brings together a joint team of hospital and post-acute care providers to develop a new transition path, targeted interventions, and services for “Alternate Level of Care,” or ALC, patients, i.e., patients who are no longer acutely ill but cannot live on their own and prove difficult to discharge into the next appropriate level of care due to their medical, mental health, and social challenges. The pilot has already successfully transitioned more than 60 ALC patients—some who were hospitalized for months and even a year—into long-term care beds in the public health system’s top-ranked post-acute nursing facilities. Once expanded system-wide, the program is expected to save the health system more than $3.5 million annually.

“Hospitals throughout the country struggle with how to handle ALC patients,” said Stanley Brezenoff, NYC Health + Hospitals interim president and CEO. “We’ve always had the components of an integrated system, but we are now taking advantage of the opportunities that real integration presents. And this is a great example of a win-win that our system transformation is creating.”

“No one wants to be in a hospital any longer than medically necessary. Yet too many adults commonly face obstacles for placement into long-term care facilities due to health insurance status, cognitive impairment, mental health conditions, inappropriate housing options, and limited nursing facility beds,” said Maureen McClusky, Senior Vice President for Post Acute Care. “We saw an opportunity to remove the barriers and give these patients a better and safer quality of life, to more thoughtfully integrate our services system-wide, and to save the system dollars.”

“Given the immense challenges hospitals face in discharging long-stay patients, the goal becomes ensuring they continue to receive high-quality care,” said Greater New York Hospital Association president Kenneth E. Raske. “With the ‘Better Way to Live’ program, NYC Health + Hospitals is not only providing their ‘permanent patients’ with the very best care, but also finding ways to safely transition them to a more appropriate care setting. With this stellar concept, NYC Health + Hospitals’ entire leadership team has once again shown its vision and deep commitment to patient care.”

In the pilot, which launched four months ago, 62 patients made the transition from NYC Health + Hospitals/Bellevue to one of three post-acute care facilities in the public health care system: NYC Health + Hospitals/Coler on Roosevelt Island, NYC Health + Hospitals/Carter in Harlem, and NYC Health + Hospitals/Gouverneur on the Lower East Side.

Under the pilot, a team from NYC Health + Hospitals/Bellevue holds a weekly teleconference with the leaders of the participating post-acute care facilities to discuss possible candidates for the program—their clinical needs, efforts to transition them home (with or without home care), related social concerns, and any other factors that need to be weighed. Each case is assessed independently, and when transition to a post-acute care facility is recommended, the team discusses which facility is the best fit for the patient, as well as any particular accommodations that must be made to address a patient’s unique needs.

“Hospitals are designed to address acute health issues, not to meet the long-term stay needs of our patients,” said William Hicks, CEO of NYC Health + Hospitals/Bellevue. “Our pilot is important to improve the lives of patients and to conserve valuable resources for the hospital and the system.”

“While important, the financial benefits pale in comparison to the vast difference in quality of life that these patients have experienced,” said Robert Hughes, CEO of NYC Health + Hospitals/Coler, the system’s 815-bed post-acute care facility on Roosevelt Island. “Some of the patients transferred to us we can rehab and transition back home. Others stay with us long term.”

One Patient Story

Ms. T. was admitted to NYC Health + Hospitals/Bellevue following seven years of homelessness. Her acute illness was addressed, but she could not care for herself. She lacked appropriate housing options and needed 1-to-1 observation to keep her from injuring herself or wandering off. A regular nursing home placement proved impossible, and the hospital had no other discharge options. Hospital officials say that, while in the hospital, her shyness and delicate mental state were amplified by limited activity options and minimal social interactions. Ironically, she also faced greater health risks associated with long hospital stays.

A team from NYC Health + Hospitals/Coler came to the hospital to assess Ms. T.’s appropriateness to transition to the facility’s Memory Care Unit. While she was able to communicate well, she had significant memory issues and was determined to be a good fit for the unit.

After a successful transition, Ms. T. now moves freely and independently throughout the unit, and she no longer needs 1-to-1 observation. The social environment has helped her overcome her initial shyness, and she participates in a number of unit activities. She listens to her own music on her personalized iPod. The right level of care in the right environment has made possible the weaning of Ms. T. off her antipsychotic medications completely.

Plans are underway to expand the “Better Way to Live” program to all 11 hospitals and five post-acute care facilities in the system in 2017. Through One City Health—the Performing Provider System led by NYC Health + Hospitals as part of the State’s Delivery System Reform Incentive Payment (DSRIP) program—other skilled nursing facilities in the community are also participating. On any given day, NYC Health + Hospitals has approximately 230 ALC patients within its system.


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