Multidisciplinary patient management by means of a high social risk screening tool

The long-term goal in this study was for the Memorial Hospital of Salem County, Inc (MHSC), to create a seamless system of continuity of care for patients. This continuity of care begins before patients require acute admission through the hospital course and extends beyond discharge and into the post-hospital setting or alternate care situation.

In a retrospective study in 1993, through the first 6 months of 1994, it was discovered that MHSC patients experienced a longer-than-average Medicare length of stay than was seen in other hospitals. MHSC embarked on a program to reduce discharge planning request time to the social work and home care departments by using a patient screening system that began at the time of admission. The nursing, social work, and home care departments collaboratively designed a system that allowed for immediate transfer of vital discharge planning information to the social work and home care departments at the time of the patient's admission. A tool was jointly developed called the multidisciplinary patient management record.

The benefits of this process far exceeded the cost of implementing the tool. The average skilled nursing facility length of stay decreased below the national average by almost one full day. Patients experienced earlier access to social service intervention: discharge planning needs were identified more accurately; and the social services and home care departments' productivity rose because they could anticipate problems before a crisis arose.

Critical to the success of this overall effort was not designing the new tool, but integrating the tool into a reengineered multidisciplinary patient management process.