At Spectrum Health Butterworth and Blodgett Hospitals in Grand Rapids, MI, patients who are likely to have complex discharge needs are identified early in the hospital stay and referred to a multidisciplinary Complex Transitions Team, which develops a plan of action designed to remove barriers and produce a smooth transition to the next level of care.
Before the initiative started, a multidisciplinary team reviewed the cases of patients who were in the hospital more than 15 days and determined that many patients with long stays were really sick and did not have complex transition needs.
“We looked among our patients to see what population is really complex and determined that they fall into three categories, and many of them fall into two of the categories or all three,” says Tali Harris, MSN, RN, ACM, supervisor for care management for Spectrum Health/Blodgett Hospital.
Many patients with complex discharge needs have financial issues, no insurance or are underinsured; they have complex medical needs that can’t be met in a community setting; and/or they have psychosocial problems with a lack of resources and appropriate settings for placement, Harris adds.
“We did extensive literature reviews, including the Centers for Medicare & Medicaid Services’ Conditions of Participation. Over and over, the literature stated that a well-designed discharge planning process takes a team approach and a collaborative partnership with post-acute providers,” Harris says.
Members of the Complex Transitions Team include representatives from care management including social workers and nurses, the hospitals’ care management supervisors, the care management director, the utilization management medical director, a representative from the hospital ethics staff, representatives from Spectrum Health’s post-acute facilities including rehabilitation, home care, and skilled nursing facilities, and a representative from Priority Health, Spectrum Health’s health plan.
Every patient who is admitted is screened by a case manager who completes the initial assessment within the first 24 to 48 hours of admission. The case manager looks at the patient’s support system or lack of support, potential post-acute needs, psychological situation, financial status, and history of admissions or emergency department visits. Patients who are likely to have complex discharge needs are referred to the Complex Transitions Team, says Britt Thompson, MSN, RN, clinical manager, care management for Spectrum Health.
The Complex Transitions Team meets once a week and goes through the list patient by patient. Team members who cannot attend in person dial in on a conference line.
Individual team members also review the patient charts every day, Thompson says.
The primary case managers for each patient are encouraged to come to the meetings and present their cases. In their absence, the supervisor presents the case.
The team discusses each patient’s situation, what has been tried, and what has worked in other cases. “We look at how we can make a difference and each member of the committee looks at the case from his or her perspective. For instance, the ethics representative may ask if what we are suggesting is what the patient really wants. Sometimes we don’t have any ideas and the group brainstorms to come up with a creative plan,” Harris says.
The members have different clinical backgrounds and different experiences and each brings a very different perspective to the table. Often, they can suggest things that the hospital clinical staff didn’t think of, Thompson says. For instance, the representative from a skilled nursing facility suggested an approach to preventing the elderly from pulling out their IV lines with a method that did not involve chemical or physical restraints.
“This intervention has proven to be very effective, facilitated a timely discharge, and ultimately avoided a readmission,” Harris says. “It really does take a village to ensure an effective transition,” she adds.
The Complex Transitions Team develops a plan of action taking into account the patient’s and family’s input, she says. The case management supervisor, case manager, and social worker carry out the plan with the help of the rest of the healthcare team.
The team looks for trends that occur repeatedly in the system and brainstorm about ways to improve, Thompson adds. “When we discover a pattern, we are proactive and take action on the issue. We feel like we are making a meaningful difference patient by patient as well as at the system level,” she says.
For instance, patients with serious psychiatric illness and complex medical needs are challenging to place and are at high risk for readmission, she says.
“Through the work of our Complex Transitions Team, we determined that these patients needed to be placed in subacute rehabilitation and that we needed to support the facility in managing the patients and not sending them back to the emergency department when they have psychiatric problems,” she says.
The team is in the process of developing a pilot project with a skilled nursing facility to provide care for patients with both complex medical and psychiatric needs. “We have been meeting with the upper level leadership from the skilled nursing facility and have brought in our psychiatrists to these meetings,” Harris says.
When patients are placed on the Complex Transitions Team list, they stay there forever so the team is informed when they are hospitalized again. “This way, we know to find the history and not start from square one. If the patient is in the emergency department, we can intervene and prevent the admission if it is not medically necessary,” Harris says.
The hospitals’ emergency departments are staffed by case management social workers 24 hours a day. The emergency department social worker can intervene on an as-needed basis to assist with patients on the Complex Transitions Team list who come into the emergency department.
The case managers may go to see them in the emergency department or call the social worker on duty and explain the patient’s situation. The social worker determines what services the patient needs to help avoid a hospital stay. The goal is to connect patients who are high utilizers with support services instead of admitting them, Harris says.
“Our team and its work is ongoing and evolving. It’s getting better and better. We have seen a consistent decrease in length of stay and in the future will be adding more service lines, including pediatrics,” Harris says.
