On any given day, all 110 acute care beds in UTMB Hospital Galveston are full.
While some patients are preparing for discharge, new patients are brought in by bus, ambulance and vans from prison units all over the state. As the state’s aging prison population requires increased medical care, the maximum security hospital on UTMB’s Galveston Campus often faces a challenge: there aren’t enough beds to go around.
“It’s like playing musical chairs with hospital beds,” said Dr. Olugbenga Ojo, chief medical officer of Hospital Galveston (HG). “Trying to find infirmary beds at units across the state for offenders being discharged from HG who still need some sort of nursing home-type care is tough—there are only 483 infirmary beds for a prison population of about 120,000. Oftentimes, patients end up staying at HG while we try to find infirmary capacity for them, and that increases their length of stay and affects the ability for other patients to be brought to our hospital.”
Improving the average length of stay (ALOS) and patient throughput—the process of moving patients through the treatment system—became a major focus for HG over a year ago, when the ALOS peaked at 9.66 days.
“We knew we had to do something,” said Marjorie Kovacevich, associate vice president of Hospital Galveston. “Only patients who are sick and need to be in the hospital should be here—otherwise, it’s not the best place to be for a patient. So we came up with several interventions and goals to ensure patients are in the hospital for the appropriate length of time.”
One intervention included incorporating Progression of Care Rounds (POCR), which are daily multi-interdisciplinary meetings where the care team discusses each patient in the unit.
“We needed to replicate the standard of care provided with regards to discharge planning in Jennie Sealy Hospital. The whole premise is to have a proactive approach, talking about the patient’s needs early on and ensuring care provided is patient-centered as well as promptly identifying barriers to the discharge process,” said Kovacevich, adding that discharging patients from a correctional managed care setting has unique nuances. “For example, part of our discussions include taking into consideration an offender’s custody level and coordinating sufficient security for transport to and from HG in a timely manner.”
Ojo says the POCR rounds have now been integrated into all HG units and have helped increase communications among all team members, including case management, bed placement, TDCJ security, nurses and physicians.
“By opening the lines of communication and raising the level of collaboration, we are seeing patients get what they need when they need it—they aren’t waiting around,” he said. “I always tell our medical staff to advocate for their patient, don’t settle for mediocrity. If a patient needs a procedure or needs to be transported somewhere, don’t settle for tomorrow. As you can imagine, if one thing doesn’t go right, it pushes everything backward. We always want to provide a coordinated, seamless transition of care because when you do it right, the chances of the patient coming back as a readmission is much lower.”
In addition to daily POCR rounds, Ojo leads a length-of-stay meeting twice a week to discuss patients who have been in the hospital for five days or more. In addition, an email escalation system has been put into place to ensure discharge paperwork is processed efficiently.
Hospital Galveston also has acquired a multi-purpose vehicle to help transport patients to and from units.
“We have a ‘no patient left behind’ motto,” said Kovacevich. “In the past, patients may have had to wait days for transportation to pick them up and take them to units in remote places several hours away. Now, that doesn’t happen. We have a driver and security available to take the patient where they need to go.”
Ojo adds that the state legislature recently agreed to create more than 160 sheltered housing beds at three units to provide a supportive environment for offenders who do not require infirmary care but have medical needs that cannot be met in a general population environment. UTMB Correctional Managed Care helped identify patients who could be transitioned from infirmary beds to the sheltered housing beds, essentially freeing up additional infirmary capacity for patients who are dependent on that level of care for their activities of daily living.
Since these various initiatives have been put in place, HG has seen a steady decline in the ALOS, going from nearly 10 days in September 2016 to 6.96 in November 2017. At the same time, patient throughput has increased, allowing more patients to be treated and improving public safety by reducing the number of offenders in free-world facilities.
Ojo says HG staff have handled the change in culture well and continue to strive to provide Best Care for the population they care for on a daily basis.
“It’s been a collaborative effort—we are all in this together,” he said. “It’s tough getting to the top but staying at the top is even tougher, so we can’t rest now. Our goals are to take quantum leaps and be transformative with regards to quality of care. We will provide Best Care for every patient, every time by providing care that is evidence-based and patient-centered.”