28/10/2023

DISCHARGE PLANNING
Reduce Readmission & Length of Stay
Dr. A. Rousdy Noor, MMRS

Declaration of Alma Ata 1978

Health equity

Universal access to
HEALTH SYSTEMS
people - centered care

Healthy communities

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The Trend….
Hospital Centerism

Commercialization
HEALTH SYSTEMS

Fragmentation

HEALTH IS HUMAN RIGHT

Health care cost prevent 1 BILLION people from seeking health care

1/3 South East Asia and Africa

are force to borrow money or sell assets
to pay for health care

and push 100 million into poverty each year

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Health
Systems
Health Equity

Universal access to
people-centered care

TREND
Healthy Community
Hospital-centrism

Commercialization

Fragmentation
HEALTH CARE REFORM

Mewujudkan UHC itu bukan hanya

sebagai syarat untuk kesehatan
yang lebih baik, melainkan juga
sebagai upaya untuk pemenuhan
hak yang sama bagi setiap orang

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INDONESIA 2019

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“Bangsa ini tetap tidur dalam

impian kacau tapi indah.
Seorang dokter tak bisa
hanya menyembuhkan luka
pada badan seorang pasien,
tapi juga harus
menyembuhkan luka
sebuah bangsa yang
sedang sakit.”

dr. Wahidin Soedirohoesodo

UNIVERSAL HEALTH
COVERAGE 2019

Health Equity9

Extent of Population
Coverage
Demand Health Care
•Out patient visits
•Hospital Admissions
Extent of Health Service
Coverage

TRIPLE BURDEN DISEASE

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Universal Health Coverage

sistem perawatan dan pelayanan kesehatan yang menjamin semua penduduk di suatu
negara atau wilayah tertentu memiliki akses untuk mendapatkan layanan kesehatan

PEOPLE ECONOMIC

High Quality Care Effective Cost

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COMPARISON

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COMPARISON
BEFORE AFTER

Customer Customer

Health
Health System
System

Supplier Supplier

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Change in Economic
Structure of Indonesian Hospital
BEP
High
TOTAL COST
REVENUE/COST

BEP

REVENUE

FIX COST

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Low

Low VOLUME High

Decreases in reimbursement have increased the break even volume

Hospital financial challenge

You Order the The costumer

good or service pays you
You send
You get the the invoice
invoice
You pay
the supplier
You deliver
Health service

Order to Pay
(buyer side)) Order to Cash

SHORT VS (seller side)

LONG

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RUMAH SAKIT PENUH UNTUNGNYA BESAR ??

UGD ramai KARYAWAN pasti Sejahtera???

Tingkat Hunian tinggi Uang RS banyak???
2

CASH FLOW:
Cash inflow
The Pulse of your
(revenue from
sales)) Business
Cash Outflow
(business overhead))

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Optimizing Patient Flow

Mengoptimalkan Alur Pasien

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Cepat Masuk / Cepat Keluar

DISCHARGE PLANNING
Reduce Admission & Length of Stay

Key part of Optimizing

Patient Flow

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"Fasilitas kesehatan yang terbukti melakukan penolakan terhadap hak-hak

peserta JKN dapat dikenai sanksi sebagaimana tertuang dalam kontrak kerja
sama dengan BPJS Kesehatan,"

"Sanksi bisa berupa teguran tertulis hingga pemutusan kontrak kerja sama."

DISCHARGE PLANNING
Reduce Admission & Length of Stay

Customer Satisfaction Increase Profit Forecasting Capacity Increase

Level of Care

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DISCHARGE

PLANNING SCHEDULING

WHAT WHEN

HOW WHO
PPA +/- Case Manager DPJP

MITOS ATAU NYATA?

HAMBATAN ATAU DUKUNGAN?

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01
Effective discharge is seen as less important
than the admission process – we concentrate
on the front end of the system (admissions)
and not on the back end (discharges)

Discharge dianggap kurang penting

dibandingkan Admission

Konsentrasinya lebih kepada Bagian depan

(admisi) dan bukan di belakang
(Kepulangan)

02
Clinical management plan does not include
expected date of discharge (EDD) based on
an anticipated length of stay (LOS) resulting in:

– discharges mainly happen in the

Afternoon even at night
– fewer discharges over the weekend and
National holidays
– patients staying longer in hospital than
clinically necessary
Tidak menuliskan tanggal rencana KRS (Keluar
Rumah Sakit), sehingga KRS seringkali sore atau
malam, KRS sedikit saat weekend/ hari libur, LOS
pasien lebih lama dari yg seharusnya

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03
No framework to plan the discharge

lack of clearly defined roles and

responsibilities amongst multi disciplinary team around
management of discharge

multi-disciplinary team unclear about knowledge, skills

and competencies needed to support discharge
decisions
Tidak ada kerangka kerja

Belum Jelas peran masing2 PPS yang terlibat

dalam management of discharge

Tim PPA belum jelas mengenai pengetahuan,

ketrampilan, kompetensi yg diperlukan untuk
mendukung keputusan untuk discharge

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Feelings that nurse and AHP-initiated
discharge is too ‘risky’ or concerns
about patient safety

Patients/carers are not involved in

decisions and are unable to plan for
discharge.

AHP = PPA (Indonesia)

Adanya perasaan terlalu beresiko bila
merencanakan kepulangan, atau merasa
tidak safety untuk pasiennya

Pasien/yg ngerawat tidak dilibatkan dalam

pengambilan keputusan atau tdk bisa juga
ikut merencanakan kepulangan

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PUSIIIIIINGG

GLOWIIIING

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HOW TO DO IT RIGHT

PUSIIIIIINGG GLOWIIIING

discharge decisions are made following the

doctor’s assessment of the patient on
admission,

and patients and carers are informed about the

expected date of discharge early in their stay

DPJP sesegera mungkin menulis tanggal kira2

(estimated date) kapan pasien KRS. Lalu sampaikan
ke keluarganya secepatnya. Secepatnya itu
maksudnya dalah semakin cepat semakin baik.

1. Plan the date and time of discharge early

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ANGRY DOCTOR?

DISCHARGE

PLANNING SCHEDULING

WHAT WHEN

HOW WHO
AHP +/- Case Manager Doctors

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HOW IF
DOCTORs
REFUSE
TO DO SO…..

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British National Health System

Has analyzed Patient flow/journey dividing them into three patient categories

Runners

unique
High Volume, requirements,
Standardized
Volume

unpredictable
pathway, highly patterns of demand,
predictable and, and potentially long
in more than and complex
90% of cases, pathways
Specials
planned
Additional + Strangers
plannable

Patient Categories

Patient Pareto Analysis

Predictable
Length of Stay

‘80% of the benefits will be found in the simplest 20% of the system,
and the final 20% of the benefits will come from the most complex 80% of the system’.

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WHERE DO I
GET THE
DATA?

2. Patients are discharged using a

criteria-based process
There is a range of discharge planning tools and guidance available outlining the
different criteria that should be considered when planning patient discharge.

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DISCHARGE

PLANNING SCHEDULING

WHAT WHEN

HOW WHO
AHP +/- Case Manager Doctors

Emergency Patients Elective Patients

Expected Date of Discharge (EDD) based on anticipated length of stay

Simple Discharge Complex Discharge

CCM
MPP
Patients meets Clinical Patients meets Clinical
Criteria for Discharge Criteria for Discharge
(CCD) (CCD)

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Clinical criteria for

discharge (CCD)?
Discharge criteria guideline was based on a
review of the medical literature and empiric
evidence on the time to reach clinical stability

The EDD and CCD are clinical, not managerial.

CCD Example

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CCD Example

Pasien meninggal di RS sekitar hari rabu 19 April sekitar jam 19.00 (masuk berita dan viral di jam 21.44)

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SIMPLE DISCHARGE

Patients with simple discharge needs make up

at least 80% of all discharges.
They are defined as patients who:
■ will usually be discharged to their own home
■ have simple ongoing care needs that do not require
complex planning and delivery.

COMPLEX DISCHARGE

Complex discharges relate to patients:

■ who will be discharged home or to a carer’s home, or to
intermediate care, or to a nursing or residential care home,
and
■ who have complex ongoing health and social care needs
that require detailed assessment, planning, and delivery by
the multi- professional team and multi-agency working,
and
■ whose length of stay in hospital is more difficult to predict.

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The Healthcare Continuum:

COMPLEX DISCHARGE

CASE DRG
MANAGER MANAGER MPP CASE MIX

SOCIAL
WORKER ??????

UNITED STATES INDONESIA

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This includes checking take-home medications

and transport (including transport provided by
family or friends).

For stays of over 48 hours, the discharge

planning checklist should be completed 24 hours
prior to discharge

Melakukan koordinasi dan mengecek segala

sesuatunya yang berkaitan dengan kepulangan
pasien. Check list untuk kepulangan pasienyg MRS
lebih dari 48 jam, setidaknya sudah lengkap 24 jam
sebelum pulang.

3. Co-ordinate and check everything is in

place 24 hours before discharge

DISCHARGE
PLANNING STRATEGY
Discharge Planning strategy focuses on engaging the patient and
family in the discharge process from the hospital to home.

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Include the patient and family as full partners in the discharge planning process
Discharge Discuss with the patient and family five key areas to prevent problems at home:
Educate the patient and family in plain language about the patient’s condition, the
Planning discharge process, and next steps at every opportunity throughout the hospital stay
Assess how well doctors and nurses explain the diagnosis, condition, and next steps in
Strategy the patient’s care to the patient and family and use teach back.
Listen to and honour the patient and family’s goals, preferences, observations, and
concerns.

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Discharge 5 Key Areas

1.Describe what life at home will be like
Planning 2.Review medications
Strategy 3.Highlight warning signs and problems
4.Explain test results
5.Make follow up appointments

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4. Timely and accurate

communication for discharge
About 20% of patients have more complex needs and may require additional input
from other professionals such as social workers, therapists, etc. The involvement of
additional people makes co-ordination and planning even more critical.

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MULTI-
DISCIPLINE
TEAM

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