Patients with unusually difficult obstacles to transitions can end up with long lengths of stay or too many ED visits and rehospitalizations. A complex care team is one way to solve this problem.

• A complex care team can help patients with financial, cultural, medical, and other obstacles.

• The team works with physicians, specialists, and other providers and organizations to ensure as smooth a transition as possible.

• Within a year, the program saved 454 hospital days and helped patients avoid an estimated 100 readmissions.

A German expat was in the Connecticut hospital for four months. She had lived and worked in the United States for her entire adult life, but never became a U.S. citizen. So, at a critical time in her life when she suddenly was too ill and frail to work, she had no means to pay for her own care. She was not eligible for Medicare or Social Security, and was unable to cover the costs of care at home or in a nursing home.

“We repatriated her back to Germany, which was her only option, because once there she was eligible for entitlements and care,” says Michelle Wallace, BSN, RN, ACM, complex case coordinator in complex case management practice (CCMP) at Hartford Hospital in Hartford, CT.

For the German patient, CCMP worked with a social worker and the German consulate in Boston to help her obtain a passport and find a nursing home where she could stay when she arrived in Germany, Wallace says.

“That took hours and hours of time each day, calling the consulate and trying to move her case along,” she recalls.

CCMP assists with the transition of the toughest cases, providing continuity for those who have little to no support when everything goes wrong.

Patients who require long lengths of stay (LOS) often have needs that far outweigh the resources available in most case management programs. At Hartford Hospital, the four-year-old complex case management practice handles most of these cases. From October 2016 through September 2017, the program saved 454 hospital days, avoided an estimated 100 readmissions, and prevented 27 ED visits.

“Initially, two part-time staff — a social worker and case coordinator — were charged with transitioning patients with an extremely long length of stay,” Wallace says.

The healthcare system and Hartford Hospital adapted to meet the needs of its patients.

Consultants to the team include a behavioral healthcare coordinator, a dialysis case coordinator, a heart failure case coordinator, and others.

“They are disease-specific and collaborate with hospitalwide case management,” says Jasmine Rivera, BSN, RN, ACM, BC, complex case coordinator at Hartford Hospital.

“They’re available to CCMP for expert consultation,” Rivera says.

“We are a unique team of people who cross various departments, and the organization has allowed us to work together,” says Debra B. Hernandez, MSN, APRN, BC, complex care advanced practice nurse at Hartford Hospital.

They started to work together in 2015, and it took three months to recognize the value of the team partners.

“Michelle was working on long LOS patients with a social worker, Jasmine was in the ER trying to transition patients home rather than having them admitted to the hospital, and I was working in the department of medicine, helping with throughput issues: medical, psychosocial, or financial,” Hernandez says.

“We identified that we shared a lot of the same patients,” Wallace adds. “We started to informally meet and collaborate.”

The team has a multidisciplinary approach and broad expertise. For instance, Hernandez collected data and understood issues related to medical complexity. Rivera’s experience in the ED gave her a clear understanding of readmissions and their causes. Wallace knew more about complex dispositions and payer issues.

Together, they identified goals and developed a risk stratification tool to triage referrals, Rivera says.

“We took our knowledge and research into risk tools, and came up with our own risk stratification triage tool that we’ve been using for two years,” Hernandez adds.

CCMP continues to study and tweak the tool, expecting to eventually copyright and publish it.

The complex case management team collaborates with any multidisciplinary team members, including providers, caregivers, post-acute care facilities, home care agencies, neighbors, emergency medical services, pharmacies, transportation entities, and state agencies.

“It takes a village and extends throughout the continuum of care,” Wallace says.

For example, CCMP helped a dying patient on a ventilator in ICU transition to his home to fulfill his wish of dying in his own bed.

“We participated in the difficult discussion with the patient, his family, and ICU provider,” Wallace says. “Then we collaborated with the palliative medicine team to ensure his symptoms were being aggressively treated.”

Working with the home hospice team, they planned what his care would be once he was home. Communication with the EMS team was essential as they performed the necessary transition from mechanical ventilation to a tracheostomy mask, Wallace notes.

“The patient lived several days at his home with his family at his side,” she says.