Discharge planners are increasingly confronted with the challenge of coordinating transitions for patients with complex needs who no longer require acute care but can’t easily be discharged to home or to a postacute facility. As the landscape of patient needs evolves, hospitals and nursing homes are seeing more patients with homelessness, mental health conditions, and substance use disorders, often alongside cognitive and other functional impairments.
The Challenge
The growing complexity of discharge needs, coupled with a shortage of housing and appropriate support services, has led to extended stays in California’s hospitals and nursing homes. According to a 2023 California Hospital Association survey (PDF), patients remain on average 16 days longer than necessary in acute psychiatric hospitals and 14 days longer in general acute hospitals. This results in significant system inefficiencies, with one in five beds in psychiatric facilities and one in 16 beds in general acute hospitals occupied by patients ready for discharge but facing delays.
The Playbook Solution
The Playbook for Complex Discharges is designed for leadership and frontline staff at organizations managing complex discharges from acute hospitals or skilled nursing facilities. It offers actionable recommendations for effective coordination, collaboration, and partnership at both the patient level and the system level. The playbook is accompanied by four patient vignettes, each describing a fictional patient with complex needs awaiting discharge from a hospital or nursing home and demonstrating how Medi-Cal benefits and services can be deployed to facilitate a person-centered discharge.
Who Can Benefit?
This playbook serves a wide range of professionals, including:
- Payers. Managed care plans, mental health plans, Drug Medi-Cal programs, and Drug Medi-Cal Organized Delivery System programs
- Health care providers. Hospitals, skilled nursing facilities, and recuperative care facilities
Use the Playbook
- Education and awareness. Increase understanding of community-based services like Enhanced Care Management and Community Supports to facilitate transitions to the least restrictive settings.
- Improving outcomes. Implement promising practices to enhance patient outcomes.
- Capacity planning. Encourage local and regional planning to address gaps in care capacity.
Explore the Playbook for Complex Discharges to enhance your organization’s ability to manage complex discharges effectively, ensuring better outcomes for patients and more efficient use of health care resources.
The playbook, patient vignettes, and an infographic calling visual attention to the challenge are all available for download below.
