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April 3, 2020

7 lessons on discharge planning during Covid-19 from UW Medicine

Daily Briefing

    Hospitals across the country are looking to post-acute providers for help offloading excess patient volumes to make room for an expected surge in Covid-19 patients. At the same time, post-acute providers face unique challenges protecting their patients and staff from Covid-19, and require support from upstream providers to take on this additional responsibility.

    Nursing homes: The front line in the fight against Covid-19

    Last week, we spoke with UW Medicine in Seattle, Washington, to learn how leaders in one of the earliest-hit states were addressing this challenge. Our conversation revealed seven lessons about how to approach discharge planning and acute/post-acute partnerships during the Covid-19 pandemic.

    1. Leverage state waivers to move "difficult-to-place" patients out of the hospital. One of the first steps to freeing up additional inpatient beds was identifying discharge destinations for state-funded patients that were stuck in the hospital. UW tapped into additional state funding for Medicaid patients, grants to fund guardianship, and waivers of specific discharge planning requirements to quickly move these patients to another site of care.

    2. Discharge as many patients home as clinically appropriate. The discharge planning team at UW has adopted a "home-first" strategy to reduce the risk of patients picking up the infection at another facility, or, if they have already been exposed in the hospital, spreading the infection downstream. The UW team noted that the stay-at-home order in Washington has actually helped discharge planners send more patients directly home because more family caregivers are now available to help patients post-discharge.

    3. Set expectations with post-acute providers about your current discharge strategy and testing capabilities. As UW seeks to both discharge more non-Covid patients to post-acute providers and assist them in their infection prevention efforts, clear and early communication has been key. One early barrier they had to overcome was that most nursing facilities wouldn't accept hospital discharges unless they had received two negative Covid-19 tests—even for asymptomatic patients with no history of Covid-19. Sharing information about why they couldn't meet that request and what they could do to help ensure safe transitions has helped mitigate that challenge.

    4. Stay up-to-date on your post-acute partners' admissions strategy and requests for support. To help reduce discharge delays, the UW post-acute care team discusses overall transition strategy with each of their post-acute partners on a regular basis. Key questions include:
      • What admissions restrictions do you have?
      • What do you need to know about patients before we send them to you, so you can be as prepared as possible to meet their needs?
      • What support do you need to take on additional patients and manage cases in your own facility?
      • What can we do to help expedite transitions on our end?
    5. Gather information about post-acute preparedness to take on additional patients—daily. In addition, UW's network providers are expected to report information on their current admissions criteria, bed capacity, staffing challenges, and any potential cases to the UW post-acute team on a daily basis. The team uses that information to inform discharge planning decisions and identify new interventions they could partner with the provider on.

    6. Proactively—and actively—work with your partners to prevent infections in nursing facilities. Across the last few weeks, UW's post-acute medical director and an ARNP have been providing in-person support to prevent infections in partner SNFs. The interventions have included:
      • Providing in-person training, including on-site observation and assessment, on infection control, PPE use, and Covid-19 signs and symptoms to watch for;
      • Sharing adapted PPE conversation protocols for post-acute and long-term care providers;
      • Working with SNF leaders on an isolation and cohorting plan;
      • Equipping SNF staff to effectively perform nasopharyngeal swab tests; and
      • Sharing protocols for surveillance of symptomatic patients and transitions back to the hospital.
    7. Prepare to act fast if an outbreak occurs downstream. In case of an outbreak at one of their partner SNFs, UW has staffed a "drop team" of NPs and physicians from across the system. The drop team can be deployed to one of the partner SNFs to help test patients and triage them to a higher level of care, if needed. UW hopes this strategy will help prevent unnecessary readmissions to the hospital and reduce spread within the facility.

    For more information on how UW Medicine is collaborating on Covid-19 care with their post-acute providers, see the post-acute and long-term care section of their Covid-19 webpage.

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