EXECUTIVE SUMMARY

A case management complex care team handles a health system’s most challenging patients by working toward a number of goals, including using a risk stratification tool to triage patients who could benefit the most.

• The complex care team checks with community organizations and providers to find resources that might help patients.

• One goal is to improve handoffs and communication between the complex care team and community providers and organizations.

• The team employs specific strategies to prevent readmissions, ED visits, and long lengths of stay.


Hartford Hospital in Hartford, CT, has a complex case management practice (CCMP) that works with medically and/or especially complex patients, who often experience the longest lengths of stay.

The following are some of the team’s successful strategies:

• Make referrals and triage. The team uses a risk stratification tool to triage patients who will benefit most from complex case management.

“Once we receive a referral in triage, we complete a risk assessment and then reach out to the entire team to let them know whether or not we will be following,” says Jasmine Rivera, BSN, RN, ACM, BC, complex case coordinator at Hartford Hospital.

The team makes recommendations based on the patient’s risks and establishes plans to achieve safe transition.

“Usually when we triage a patient, we determine which one of us will take the primary lead on the case, and that person assists the care team with throughput,” Rivera says.

• Address barriers to care. Based on a patient’s transition barriers, including financial, caregiver, and medical complexity, the team will identify and obtain resources to minimize the barrier. For example, if the barrier is financial, the team will look into helping the patient apply for secondary insurance coverage, such as Medicaid, says Michelle Wallace, BSN, RN, ACM, complex case coordinator in CCMP at Hartford Hospital.

If social barriers such as housing issues, financial limitations, lack of decision-maker, or legal concerns are identified, the team partners with a social worker.

“If the barrier involves the patient’s lack of ability to make medical decisions, our partnership with social work may include coordinating a family meeting, petitioning for a conservator, or completing a healthcare representative proxy,” Wallace explains.

• Improve handoffs. “We have various ways to hand off patients to the next level,” says Debra B. Hernandez, MSN, APRN, BC, complex care advanced practice nurse at Hartford Hospital.

Written discharge summaries and interagency referral forms are standard documents provided to post-acute facilities, agencies, and providers.

“If the patient is going someplace within our health system, we have an email process of handover,” she says. “If we’re sending the patient to a skilled nursing facility or back to the community, we speak with the primary care provider as part of the handover.”

Written discharge summaries accompany patients to the next transition.

“Also, we have created partnerships with clinics and community health services in our city, and the same handoff is provided,” Hernandez says.

Sometimes the patient’s case is very complex and a home health or hospice professional will visit the patient in the hospital to help facilitate the handover, she adds.

The complex care team stays involved with these patients until their cases are resolved, Rivera notes.

“If we’re involved, we stay involved until a successful transition has occurred and the patient and family no longer need our services,” Rivera says. “We don’t hand off to the team and walk away. We visit those patients in their homes or nursing facilities and communicate with staff caring for the patient, including nurses, providers, nursing home coordinators, and administrators.”

CCMP stays involved throughout the care continuum. “We talk about care of the patient and try to come up with the best plan,” Hernandez says. “We might talk about medication reconciliation and explain anything where there could be confusion.”

An example might be if the patient tells the provider that he or she doesn’t take a particular medication, although it was a prescription initiated in the hospital, she explains.

“We dig into the reason why the patient is not taking the medication, and help resolve it,” she explains. “If we in the hospital and in the community can reinforce their treatment plans, then patients have a better likelihood of adhering to treatment.”

The complex care team continues to work toward its goal of preventing readmissions and meeting patients’ needs by remaining involved with the patient in the community, she adds.

“We call this intensive case management in the community,” Wallace says. “We may prevent an admission, readmission, and emergency department visit.”

• Use readmission prevention strategies. The complex care team’s work prevented an estimated 100 admissions — including 30-day readmissions — between October 2016 and September 2017. Also, an estimated 27 ED visits were avoided.

The team focuses on keeping nonhospitalized patients out of the hospital and preventing newly discharged patients from returning to the hospital within 30 days, Hernandez says.

“For multiple-readmit patients, we do a root cause analysis,” she explains. “We analyze why that patient is being readmitted.”

Often, the problem is related to the patient not taking medication. Sometimes it’s for financial reasons. Housing might be an issue, or patients might need behavioral health strategies. Medical issues also could be related to failed treatment or technology.

“For example, maybe a patient’s feeding tube is leaking,” Wallace says. “So we arrange for the patient to come in as an outpatient to have the tube changed, preventing a visit to the ED or an admission.”

In one case, a patient suffered liver cirrhosis, which led to multiple hospital admissions. The complex case management team worked with a skilled nursing facility to transition the patient from home to the SNF. Once there, the patient’s hospitalizations greatly declined, Hernandez recalls.

• Meet community partners. “The team initially started meeting with individual community partners to explain our role, introduce ourselves, and to define our process of providing a more detailed handover if we are working with one of their patients,” Wallace says.

For partners within the health system, the complex care team will send email handovers. For other organizations, they will call or email to see if they’re interested in working with the team. This first introduction might occur when the team already is following a patient in the organization’s care.

“If a patient is here in the hospital, then it’s a great opportunity for us to reach out and call a clinic that’s not in our healthcare system,” Hernandez says. “Everybody has the same goal of keeping patients out of the hospital, and you can connect on that goal.”

• Identify patient problems. There was one patient repeatedly seen in the ED. The patient’s chief complaints were chest pain and body pain. The complex case management team found that at each visit, the patient would receive IV narcotics for the pain, and then would go into respiratory failure. This pattern was the problem, so the team created an ED treatment plan that included limiting the patient’s narcotics and alternative pain management, says Hernandez.

The patient was opioid dependent, so treatment also included helping the patient taper off the drug after discharge.

“The patient wasn’t happy with the change at first, but ultimately accepted it,” she says. “The family appreciated it.”

This type of solution would have been far more challenging without the community collaboration, she notes. Patients with opioid problems require coordination between hospitals and community providers.

“We have to reach out to the primary care provider and home care agencies to get them to support the solution on a day-to-day basis,” Hernandez says. “You might need to put a lockbox for medication in the house to make it successful.”

A home health nurse would have the only key to the lockbox. The nurse would pour the medication into cups for the patient to take at specific times every day. This way, the patient cannot take additional doses of opioids. Another lockbox uses a timer that triggers it to open with the dose at specific times.

• Target length of stay (LOS). “The other thing we’re doing at our institution is reducing length of stay,” Hernandez says. “As a complex care team, we work with patients who have difficult dispositions on a one-on-one basis, and we work with hospital leadership on strategies to help them as a population.”

This is time-consuming and detail-oriented work, but is rewarding work that has the potential of reducing the length of hospital stay for complex patients, she adds.

It can also be costly, although still less expensive than an unnecessarily long LOS.

For instance, there might be a hospitalized patient who lacks entitlements and social supports, yet requires rehabilitation. The CCMP might present the patient’s case to the health system administration after CCMP identifies potential transition options, such as providing rehabilitation while hospitalized or in a rehab facility, Wallace explains.

“It can be costly, although still less expensive than an unnecessary and extended length of stay,” Wallace says.

Other strategies might be to provide extensive family or caregiver education, home health nursing care, and in-home medical equipment.

Often, problems affecting LOS are related to social determinants of health. A current CCMP case is a patient who had a stroke. The patient is undocumented and does not have any financial or insurance resources. The patient also lacks a decision-maker and social support, Wallace states.

“To date, we have a court-appointed conservator and are pursuing a passport for the patient and a transition back to Poland,” she says.

“We look nationally for resources for people, and we look for religious organizations and charities — whatever we can find,” Wallace says. “We refer people to federally qualified healthcare clinics, where they can get psychiatric care, medication at a reduced rate, and medical follow-up.”

• Hold weekly team consults. “We have a high-risk clinical team meeting weekly with administration and providers to review our caseload and discuss patient needs,” Wallace says.

The team meetings cover readmissions, difficult dispositions, and throughput barriers. The goal is to come up with ideas of how to transition hospitalized patients without unnecessary delays.

“We try to make treatment decisions more rapidly,” Hernandez says.

Each case has unique challenges. “Right now, we have one patient from a state mental health system,” she says. “And we have another patient from a group home who is on a ventilator, has Parkinson’s disease, and is unable to swallow and cannot go back to the group home.”

The treatment plan will cover what are realistic transitions and expectations for each patient.

Each team member agrees: “We first meet the needs of the patient, and then, with the support of administration and the multidisciplinary team, we reduce length of stay and prevent readmissions,” Hernandez says.