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DHMC Shortens ‘Guardian’ Stays

Jasper J. Chen, a second year resident at Dartmouth-Hitchcock Medical Center who goes by “J.J.,” at home in Grantham with Romi, his nine-month-old Belgian Tervuren. (Valley News - Sarah Priestap)

Jasper J. Chen, a second year resident at Dartmouth-Hitchcock Medical Center who goes by “J.J.,” at home in Grantham with Romi, his nine-month-old Belgian Tervuren. (Valley News - Sarah Priestap) Purchase photo reprints »

Lebanon — There are times when patients arrive at Dartmouth-Hitchcock Medical Center, incapacitated and without someone in legal authority to decide about their care.

It doesn’t happen often — on average only once a month. But when it does, the situation can be a time-consuming and costly process to find a court-appointed guardian who can look after the patient’s interests.

The patient may be ready to leave the hospital after a couple weeks and enter a less intensive facility, such as a nursing home, but ends up staying at DHMC longer than necessary while a guardian is found.

Continuing to care for such patients not only ties up hospital beds but also puts the patient at greater risk for infection while they remain near others who are sick. This was the problem that Jasper James Chen sought to fix.

“There was a kind of gap in care,” said Chen, a medical resident at DHMC. “When it does happen, it’s not as smooth of a process as it could be.”

A year and a half ago, Chen — who goes by “J.J.” — took on the challenge of closing that gap in care as part of a project for his residency training.

Working with a team of advisers at DHMC, Chen developed and implemented reforms that have saved the hospital roughly $400,000 in hospital bed costs over the past year and freed up valuable resources as the region’s largest health care provider struggles to keep space open for new patients.

The average length of stay for guardianship patients dropped from 50 days in 2011 to an average of 31 days in the past year, a 38 percent decrease.

DHMC’s experience could serve as a lesson for other hospitals that struggle to connect patients with guardians, said Linda Mallon, executive director of the office of public guardian of New Hampshire.

“It comes up quite regularly, where a person is ready for discharge but when that person is not ready to make decisions” about their health care, said Mallon. “I applaud J.J. and Dartmouth-Hitchcock for doing the research and paying attention to this very important issue.”

Guardianship is a legal arrangement in which one person has the responsibility to care for another. Typically, this duty falls to a family member or loved one who has been named in a durable power of attorney, a written document that remains valid even if someone becomes unable to make their own decisions.

Not every patient has a durable power of attorney, however, leaving it to health care providers to work with state probate courts in appointing a guardian.

When the hospital realizes there is a need for a guardian, that is followed by a psychiatric consultation to determine whether the patient can make decisions for themselves. If the patient can’t make decisions — because of brain damage sustained during an accident, for example, or because the patient has dementia — then a hospital social worker or a family member submits a petition to the probate court, followed by a hearing and ultimately appointment of a guardian.

This process can take several days to weeks, often much longer than the person needs to recover, said Michele Blanchard, a senior care manager at DHMC who worked with Chen.

It wasn’t that DHMC’s guardianship process didn’t work, Blanchard said, but hospital staff knew it could work more efficiently.

“We asked ourselves how can we back that up and identify patients sooner, who lack the capacity to make a health care decision,” she said.

The changes Chen recommended were aimed at improving coordination among staff. Monitoring sheets were created to track where in the building patients were being cared for and what stage they were in regarding the guardian process. They noted whether paperwork been filed with the court, which probate court was used and whether family was contacted.

The hospital’s social workers became better educated about how the court process worked, and there were standards put in place to govern how guardianship petitions were submitted to the courts.

The hospital also sought to improve communication between DHMC and the probate courts. Chen and Christine Finn, director of the psychiatry residency training program, are exploring whether judges will take testimony from a patient’s psychiatrist over the telephone, for example, to speed the process along.

Finn expected there would be some improved efficiency from these changes, but said she never anticipated the level of savings DHMC has achieved.

“It’s been really impressive,” she said. “Within a short period of time, and without fancy interventions, the progress that’s being made.”

Finn said these reforms represent the first step of what she hopes will be a more long-term focus on improving how the hospital connects guardians with patients who need them.

Beyond the financial savings for DHMC, the quality of care for patients has improved, said hospital officials. Being in the hospital during flu season, for example, puts patients at increased risk of getting sick.

“It’s just not the best environment for people to be in,” Blanchard said.

Plus, there are plenty of people who need those beds more than someone who could perhaps be cared for an a less intensive environment than a tertiary care hospital. DHMC is almost always near full capacity in its critical care and medical/surgical units, and officials estimate that by 2016, the average demand will exceed what is available.

The hospital plans to add beds in those two areas, but in the meantime, efforts such as this one undertaken by Chen could relieve the cramped quarters.

“I think the most progress has been made in our ability to use the resources in the best way it can be used,” he said. “Freeing up a bed.”

Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.