Optimizing Hospital Capacity: Strategies for Transitioning High-Risk Patients
Managing the transition of high-risk patients from hospital to post-acute care is a growing challenge for healthcare providers. Workforce shortages and capacity constraints, coupled with an aging population and a rise in chronic illnesses, have made the need for efficient post-acute services more urgent than ever.
When discharge tasks—such as exercise oximetry tests—aren’t coordinated, they often stack up on a patient’s final day. This lack of coordination can trigger a cascade of negative events, including discharge delays, interrupted post-acute treatments and increased readmissions. In fact, up to 30% of all hospital admissions experience a 24-hour discharge delay due to nonclinical reasons.
Identifying High-Risk Patients Through Data
Effective capacity management starts with the accurate identification of high-risk patients. Rather than using a “one-size-fits-all” approach, which is clinically ineffective and expensive, providers are turning to risk stratification. This process allows care models to be personalized based on whether a patient is categorized as high-, medium- (rising), or low-risk.
To refine this identification process, some organizations are marrying clinical data with social determinants of health (SDOH). For example, a Vizient Member Networks Performance Improvement Program collaborative involving 39 member organizations focused on the top 2% of their utilizers. By combining the Vizient Clinical Data Base with the Vizient Vulnerability Index™, they were able to identify the specific social determinants of health that these patients struggle with to better manage their transitions.
Identification varies by medical context:
- Surgical Care: Early and accurate identification of high-risk surgical patients allows for targeted perioperative monitoring and interventions, which can improve overall outcomes.
- Population Health: Risk stratification at the population level ensures that resources are allocated efficiently to the subgroups that need them most.
- Emergency Management: During disasters, identifying at-risk individuals involves understanding their unique access and functional needs to ensure they receive effective medical care and support.
Strategies for Improving Patient Transitions
To create capacity and improve patient outcomes, healthcare systems are moving away from generic care models toward targeted interventions.
Personalized Care Models
According to NACHC, maximizing efficiency requires personalized care models. By stratifying patients by risk level, providers can offer the appropriate level of resources to each subgroup, avoiding the waste associated with providing the same level of care to every patient regardless of their needs.
Addressing Nonclinical Barriers
Due to the fact that a significant portion of discharge delays are nonclinical, focusing on the logistics of the transition is critical. Coordinating discharge tasks early prevents the “stacking” of requirements on the final day, which is a primary driver of hospital congestion.
Key Takeaways for Healthcare Providers
- Avoid Generic Care: One-size-fits-all models are prohibitively expensive and clinically ineffective.
- Use SDOH Data: Incorporating social determinants of health helps identify the most vulnerable patients and the specific barriers they face.
- Focus on the Top Utilizers: Targeting the highest percentage of utilizers can significantly impact hospital capacity.
- Coordinate Early: Addressing nonclinical discharge tasks before the final day reduces the 24-hour delay seen in nearly a third of admissions.
Frequently Asked Questions
What is risk stratification in population health?
Risk stratification is the process of dividing a patient population into subgroups—typically high-, medium- (rising), and low-risk—to personalize care models and allocate resources more efficiently.
Why are nonclinical reasons causing discharge delays?
Delays often occur when discharge tasks are not coordinated, leading to a bottleneck of requirements on the patient’s last day, which can delay the transition to post-acute care.
How does SDOH impact patient transitions?
Social determinants of health (SDOH) are the non-medical factors that influence health outcomes. By identifying these struggles through tools like the Vizient Vulnerability Index™, providers can better prepare for the specific challenges a high-risk patient will face after leaving the hospital.
As the senior population grows and chronic illness becomes more prevalent, the ability to identify high-risk patients early and transition them efficiently will remain a cornerstone of hospital capacity management and patient safety.
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