Community planning and service reorganization to reduce LOS and provide better aftercare for the uninsured by the regional medical center

The unexpected failure to expand Medicaid in many states as part of the ACA has put medical facilities in Tennessee and elsewhere in the position of dealing with growing numbers of uninsured patients without significant additional resources.  To respond to this challenge, the largest medical center caring for the uninsured in the state has reorganized its coordination of care process to decrease the length of stay to more closely align with the Medicare geometric LOS for medicine services.  LOS disparities are related to lack of post-acute venues willing to accept the uninsured.     Community resources were engaged specifically with mental health providers and long term care facilities.  This service reorganization produced a significant reduction in LOS from 6.49 to 4.81 days between June and December of 2013.  Our analysis demonstrated a statistical difference in the length of stay for the combined A, B, and C medicine service, (F=13.34, p=0.006) with an adjusted R² = 57.83%.  Because of this effective planning done by the medical center and other community medical and social organizations, we have been able to decrease diversions in key clinical areas have been reduced, with greater capacity for patients needing acute hospital services.  The need for additional support for the uninsured is very clear for states not expanding Medicaid.  Our experience demonstrates a great need for communities to work together to develop partnerships and strong collaboration across the continuum to reduce waste and support those who do not have insurance.