Few studies have evaluated system-level interventions focused on medically complex, high-risk, or vulnerable patient populations, including frail elderly patients and those with complex chronic illness. Strategies assessed in multiple systematic reviews include geriatric consultation services and early specialized discharge planning according to a new technical brief published by the Agency for Healthcare Research and Quality's (AHRQ).
Substantial research gaps need to be addressed, including interventions for socially or economically vulnerable populations and patients with psychiatric or substance use disorders, contextual factors affecting feasibility of implementation, and the resources and potential savings associated with interventions to reduce length of stay (LOS).
Hospital administrative leaders, researchers and policymakers can work to reduce LOS by improving research practice, developing targeted health system interventions, and collaboratively addressing the social care needs of medically complex and vulnerable patient populations.
Two interventions (clinical pathways and case management) improved key outcomes for patients with heart failure. Clinical pathways reduced LOS, readmission and mortality (low to moderate quality evidence from a single systematic review). Similarly, case management decreased LOS and readmissions (moderate quality evidence from a single systematic review). More research is needed to confirm these findings.
For other interventions, evidence for LOS reduction was inconsistent. Only limited evidence was available for other post-discharge adverse outcomes (hospital readmission, mortality).
The evidence base examining strategies for reducing LOS is large but focuses primarily on average-risk patients undergoing elective surgery or specialized procedures, who were not the focus of this Technical Brief.
Timely discharge of hospitalized patients can prevent patient harm, improve patient satisfaction and quality of life, and reduce costs. Numerous strategies have been tested to improve the efficiency and safety of patient recovery and discharge, but hospitals continue to face challenges.
This technical brief aimed to identify and synthesize current knowledge and emerging concepts regarding systematic strategies that hospitals and health systems can implement to reduce LOS with emphasis on medically complex or vulnerable patients at high risk for prolonged LOS due to clinical, social, or economic barriers to timely discharge.
The reviews described eight strategies for reducing LOS: discharge planning; geriatric assessment or consultation; medication management; clinical pathways; inter- or multidisciplinary care; case management; hospitalist services; and telehealth. All reviews included adult patients, and two reviews also included children. Interventions were frequently designed for older (often frail) patients or patients with chronic illness. One review included pregnant women at high risk for premature delivery. No reviews focused on factors linking patient vulnerability with social determinants of health.