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Managing Complex-Needs Patients: Innovation Grant Spurs Complex Care Model

By Karen Cameron 10/6/16

 

 

A small but significant number of patients devour the vast majority of health care resources. For the U.S. health care system to succeed in its transformation, the aggressive management of these "complex needs" patients is essential.

Mercy Health has created a proven solution in western Michigan, the Complex Care model, which brings together a team of providers from across the spectrum — including competitors — to develop an integrated plan of care for patients who are identified as complex. The goal is to stabilize the patient, with the resulting outcomes being reductions in emergency department visits, length of stay, inpatient admissions and unnecessary care.

After creating the program and seeing its potential, Lauran Hardin, MSN, RN-BC, CNL, director, Complex Care, Mercy Health Saint Mary’s, Grand Rapids, Mich., applied for and received an Innovation grant from Trinity Health. The Innovation program, launched in 2014, encourages innovative thinking across the system and nurtures an environment that is safe for trying transformational, breakthrough ideas. In this way, the Innovation program is true to Trinity Health’s People-Centered 2020 vision, which provides a strategic framework to improve the health of our communities and each person we serve.

Hardin's grant allowed her to leap the program from a one-person operation to a fully trained team with a defined infrastructure, and tools and resources that would allow replication, as well as expand the number of patients being served.

Currently, the Complex Care model is being rolled out in more than 20 hospitals across Trinity Health through the ED Collaborative.

Since the Innovation program was launched in 2014, 16 grants have been awarded across Trinity Health.

“The Innovation program is considered successful only if we can replicate what has been tested in one RHM to other Trinity Health organizations,” said Anna Marie Butrie, vice president, Innovation Program and Services. “Due to the program’s support, Lauran had an opportunity to not only enhance the model in Grand Rapids, but also expand it to other RHMs.”

Complex Care

Of the Complex Care program’s success, Hardin noted, “We achieved much stronger outcomes than expected.” During the two-year period of the Innovation grant, more than 1,000 patients were served. Outcomes for the population 12 months after intervention include a 55 percent reduction in admissions, a 49 percent reduction in ED visits, a 57 percent improvement in direct expense, and a $1 million improvement in operating margin.

But for all these aggregate numbers, the greatest reward is in bringing an improved quality of life to each person served.

“When you look back into a person’s record,” said Hardin, “you can find things that help you truly understand their story. Things like mental health issues, trauma, housing, transportation — things that really make a difference in the planning of a person’s care, things we haven’t traditionally, consistently captured.”

The Complex Care Center in Grand Rapids now follows more than 1,500 patients, with an impressive average of 30 being added every month.

“A lot of our success has to do with the principle of looking at what can happen when you link resources together across systems,” said Hardin. “Another is what happens when people are trained to deeply understand root cause. The interventions are done comprehensively — medical root cause, psychiatric root cause — all the factors that are affecting instability including what we can fix in the system itself.”

In fact, “fixing the system” allows for intervention whether the patient engages in the plan of care or not.

“There are things we can do to improve the system of delivery,” said Hardin. “The patient doesn’t need to show up for that.”

But when the patient does show up, in the ER or elsewhere, an alert is generated to all those who participate in that patient’s care. In real time, the providers can see what is going on with the patient, link with cross-continuum providers, and intervene as needed.

A system-wide expansion is in process based on the findings from the Innovation grant pilot.  “The hospitals are very excited to bring the providers together and work toward stabilizing complex patients,” Hardin said. “In the ER especially, they see the patients who return time and again, but they haven’t had the framework to be able to change the pattern. In the Complex Care model, we give them the framework to make a difference. And they are finding it rewarding.”

 

About Trinity Health Innovations

Trinity Health Innovations provides pathways, funding and support that enables innovative IDEAs to grow and flourish and scale across the health system. The I.D.E.A. model — Identify, Develop, Explore and Advance — spurs this work.

 

About Trinity Health


Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation, serving diverse communities that include more than 30 million people across 22 states. Trinity Health includes 93 hospitals, as well as 120 continuing care programs that include PACE, senior living facilities, and home care and hospice services. Its continuing care programs provide nearly 2.5 million visits annually. Based in Livonia, Mich., and with annual operating revenues of $16.3 billion and assets of $23.4 billion, the organization returns almost $1 billion to its communities annually in the form of charity care and other community benefit programs. Trinity Health employs about 131,000 colleagues, including 5,300 employed physicians. Committed to those who are poor and underserved in its communities, Trinity Health is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs. For more information, visit www.trinity-health.org. You can also follow @TrinityHealthMI on Twitter.