By Jeanie Davis

Patients with complex needs can stretch the resources of even the most experienced case manager. These tend to be patients who have been admitted via the ED, not elective admissions. They are ready for discharge, but various barriers can cause complications.

“These are folks who have really novel needs,” explains Geoffrey Lake, MBA MSW LISW-S CCM, a manager of case management at Cleveland Clinic. “Whatever next step is, it is so far outside the norm, we have to figure out extra resources.”

That is when an escalation team can help. This team of “the right people” can help find solutions for complex cases, says Lake.

This team does not usurp the case manager’s role, he explains, but can be an adjunct resource during a stalemate. “Case managers are natural coalition-builders,” he explains. “They know to take the patient’s desires, interests, and goals to synthesize a medical team that will recommend appropriate resources. Case managers are experts at building an individual plan that meets the patient’s needs and goals.”

Because Cleveland Clinic regularly treats patients with complex needs, there is an escalation team that meets every two weeks to review cases presented by a case manager. “It’s not the C-suite, although in small hospitals that might be necessary,” he explains.

Escalation team members need broad control, he says. “In many hospitals, budgets are siloed. The escalation team must have the discretion to make decisions on spending hospital money and using hospital resources. They should have oversight over multiple budget lines.”

This team approach has not only generated success for these patients, but also created best practices for handling future issues, Lake adds. He cites several cases when the escalation team has been instrumental in resolving complex patient cases:

• A patient arrived in Cleveland on a tourism visa, then unexpectedly became seriously ill. He had no traveler’s insurance, and no insurance payer. “That always makes things more complex. He also was in a debilitated condition, which further complicated the situation,” says Lake.

Discharge planning for this patient was proving difficult, as he could not care for himself. He needed rehabilitation to grow stronger, but did not have coverage. In the end, the patient entered a Cleveland Clinic-owned skilled nursing facility where he gained sufficient strength to return to his home country via a commercial flight.

• An international patient was morbidly obese, bedbound, and could not be transported via commercial plane or standard air ambulance. The escalation team worked with his home country’s military to find a military flight that could accommodate him and medical staff.

• A sick, fragile patient could not accept the severity of her illness and the extensive treatment required. She did not want to be discharged to a rehabilitation facility; she wanted to stay in the hospital where she felt safe.

The escalation team put together an estimate of her hospital bill if she stayed. It described the medically necessary services her insurance would cover, and the amount it would not cover. Then, the team showed her a mockup of her bill if she went to the rehabilitation facility, where all her expenses would be covered. She decided to transition to rehab.

• A family refused to allow a patient to leave the hospital to return home. The team examined this case more deeply for abuse or financial gain if the patient stayed in the hospital. “We can get Adult Protective Services to establish a guardianship. The court then has oversight and monitoring of the patient’s progress,” says Lake.

• A patient was gravely ill, and the family had a difficult time accepting it. They demanded extended-level hospital care, with tracheotomy, which could become a long-term situation, Lake explains.

In trying to understand the family’s viewpoint, the escalation team asked the chaplain to join a meeting with the physician. The chaplain advocated for the hospital’s position on the patient’s care, and the family finally accepted the situation.

“In all these instances, the focus has to be on the patient’s needs and getting those needs met,” Lake explains. “The focus also is on ensuring the patient’s safety at all times.”

• An elderly woman was in the habit of visiting the ED several times every week with somatic medical complaints. This went on for several months. Over time, she formed a friendly relationship with the ED social worker. The person had no obvious medical need; she just liked visiting with the social worker.

The escalation team decided it was time to send the ED case manager to the woman’s home to get a better sense of her needs. She is enrolled in a home care program, with a physician making home visits.

“That one case manager visit left this lady feeling so cared for, she quit visiting the ED so often,” he says. “The ED staff became concerned about her absence and called to check on her, to learn all was well. In the end, it worked well for everyone.”

Organizing an Escalation Team

By the time a patient reaches the escalation team, the issues keeping them in the hospital are not medical — they are related to finances, availability of services, and the agreement of the family, says Lake. “A patient being in the hospital because they need medical care is the right thing. If there is a different reason, that is not good for the patient.”

The Cleveland Clinic’s team has been in place for three years. The team is comprised of the chief nursing officer and six to 10 leaders from finance, patient experience, legal, case management, and other departments.

The escalation team’s transition plans are presented to the medical team. After the physician agrees, the plans are implemented, Lake adds.

“I’m really proud of working with this team and this hospital because we really do put patients first,” he says. “Obviously, meeting fiscal targets is important, but the team focuses on what is the right thing for this patient. The folks in that room really believe the first goal has to be what’s right for this patient.”