Critical Path Network

Persistence pays off when placing difficult patients

Case study shows the benefits of networking

It took more than 260 days, hundreds of hours on the telephone, and a lot of networking and brainstorming for Chesapeake General Hospital in Chesapeake, VA, to find post-acute care for a seriously ill pediatric patient.

But persistence and patience paid off and the care management staff were able to place the patient in a pediatric rehabilitation center where he got the therapy he needed to be discharged to home.

The patient, a 17-year-old boy who suffered a blood clot in the brain that left him severely impaired, was a challenge for the 310-bed acute care hospital.

"This case was a real heartbreaking one and an example of how difficult some placements can be. This boy had multiple needs and required almost around-the-clock complex care. Because he was younger than 18, he qualified as a pediatric patient but he was the size of an adult. Everything about him was adult, except his age," says Roxana Ballinger, RN, CCM, director of care management.

The hospital's placement specialists, who are social workers, facilitate 130-150 post-acute placements in a typical month.

However, the patient — let's call him John Smith — needed placement in a pediatric hospital that could provide intense rehabilitation services. Placing ventilation patients with multiple needs is difficult in any circumstance but even more so when the patient is a juvenile. It was particularly problematic for placement specialists whose expertise is placing adult patients, Ballinger says.

Finding a post-acute placement for Smith was a team effort that involved networking with social workers and case managers at hospitals across the country, doing research on the Internet, and brainstorming in the hospital's multidisciplinary long-stay meetings, she says.

"Networking proved to be very important when we were working to place this patient. It was a big help that our staff know case managers and social workers at other facilities. You may think you'll never need these kinds of contacts;but when a case like this comes up, you need everybody's help," she adds.

The patient was gravely ill when he came in to the emergency department. He had a blood clot in his brain that resulted in peripheral neuropathy, which left him mentally aware but with an unresponsive body. The cause of the blood clot, about the size of a fist, was never determined.

The day after surgery to relieve the pressure on his brain, both of his lungs collapsed; he was on a ventilator and received IV antibiotics and IV steroids.

Eventually, he received a tracheostomy and a feeding tube but still required total care — he couldn't sit up on his own, couldn't walk, feed or dress himself. His needs were so extensive that discharging him to home, even with 24-hours-a-day care, wasn't an option.

He spent about three months in the ICU before he was transferred to the medical floor. Even then, his room had to be located close to the nurse's station, and the nurses who cared for him carried a smaller caseload because he needed so much monitoring and his care was so complex.

Smith became acutely ill and returned to the ICU twice during the 280-plus days he was at Chesapeake General.

The hospital has 11 full-time RN case managers and two PRN case managers who go wherever they are needed. Ten of the full-time case managers work on the inpatient side and are unit-based. There is a full-time case manager in the emergency department.

The case managers handle all the utilization review, Medicare review, managed care reviews, and discharge planning for patients being discharged to home who need transportation and home health.

The department includes four placement specialists who are social workers and are responsible for placements in post-acute care. Two payer specialists work with insurance companies and handle denials and appeals.

When the young man had been a patient for about three weeks, Jessica York, SW, placement specialist, began looking for post-acute placement options, taking into consideration his mother's wishes for her son to stay in Chesapeake.

"By then, his permanent skilled needs were apparent. We knew that he was going to need a lot of rehabilitation to become functional and that wasn't going to happen in an acute-care hospital," Ballinger said.

Lake Taylor Transitional Care Hospital, the only hospital in the area that took pediatric patients, had a long waiting list and the mother preferred for him to be near home.

"His mother wanted to take him home but knew she couldn't. She knew the best place would be in a rehabilitation facility so he could begin making progress," Ballinger says.

York began contacting children's hospitals in the area to find options for placing difficult-to-place pediatric patients.

"They gave us the names of a few facilities with long waiting lists. There simply are not enough facilities to take care of young people who are critically injured and likely to have care needs for the rest of their lives," she says.

York began contacting hospitals further and further from Chesapeake, eventually, scouring the entire East Coast, looking for a bed for Smith. Meanwhile, he remained at Chesapeake General Hospital where the total cost of care was growing increasingly expensive and difficult for the hospital to recoup.

Smith's insurance company paid for some of his acute care but denied any rehabilitation benefits, which made it even more challenging to find a place for him.

"Medicaid was going to be his payer for rehab and Medicaid in the state of Virginia doesn't pay much. The patient was on a ventilator, a tracheostomy, and had a feeding tube. He needed intense physical therapy, occupational therapy, and speech therapy. His needs were complex and that made it even more difficult to find a place for him," Ballinger says.

Many times, the rest of the staff pitched in and took care of York's caseload so she could work full time on finding a place for the young man.

"It was highly unusual for a staff member to devote entire days working on one person's case but it was the only way to make any headway with him. If she hadn't spent so many hours on the case, he would have been here much longer," Ballinger says.

The entire care management team supported York throughout the process.

"She became very emotionally involved in the case and went out of her way to do whatever she could for the patient and family," Ballinger says.

The social work team spent a lot of time with the mother, helping work through the emotional trauma of having a critically ill child. They helped her apply for Medicare and arranged transportation so she could visit her son in the hospital.

York made frequent follow-up calls to the post-acute facilities, which had the facilities to care for a patient such as Smith.

"These facilities wanted enormous amounts of information about him and wanted constant updates. We had to fax some information. Other facilities wanted it electronically. We were constantly pushing to find a place," Ballinger says.

Finally, as York networked with other facilities, someone referred her to Kluge Children's Rehabilitation Center, affiliated with the Children's Hospital at the University of Virginia. After studying his condition for a few weeks, they agreed to take Smith.

"They looked on him as a young boy with a life ahead of him. Since he was on Medicaid, taking him was not a good business decision but they looked on him as a challenge, as someone they could help," Ballinger says.

Smith's mother, who had insisted that her son stay at Chesapeake General even when he was stable enough to be transferred to a pediatric facility, was anxious about transferring him to Kluge.

"She was very nervous about him leaving the hospital. He had been here so long, he felt like this was his home and so did his mom. She knew the nurses and the therapists and was comfortable with everybody," Ballinger says.

The care management team assured her he would get good care and put her in touch with the Kluge staff. They explored temporary housing options in Charlottesville and offered the mother a bus ticket so she could be with her son as he adjusted to a new facility.

York kept in touch with Kluge and learned that the young man was released to home with 24-hour care.

Ballinger offers these tips for placing difficult patients:

  • Be patient and keep trying. Often it takes contacting the same facilities over and over to remind them you have a patient who needs their services.
  • Designate someone to work on the case almost exclusively.

"These cases are so complicated that no one can carry a full load of nursing home and rehab placements and handle a complex case," she says.

  • Network constantly with everyone you know. By talking to one person who referred her to another and another, York found Kluge Children's Rehab.