What to Do With the Complex Patients

Hospitalizations appear to be more complex, requiring greater attention from the multidisciplinary team.

As we know, with the growth of outpatient surgical centers, advances in medical technology, and the shift of payers’ understanding in what they will consider to be an inpatient episode of care have all impacted the hospital patient composition.

Hospitalizations are seemingly more complex, requiring more attention from the multidisciplinary team. Prior to COVID, the focus on long length-of-stay patients had been a known, standardized process; however, hospitals and thus case management programs, including our beloved physician advisors, are feeling new pressure in the “Why are they still here?” discussion. During our great staffing exodus, the beds may be available to the patients rolling through the emergency room and out of the surgical suites; however, there is limited staffing across the systems to care for them in all areas. Fewer nurses, physical therapy is overwhelmed by consults, and environmental services (EVS) folks have been leaving just as fast as nursing for better wages and less stressful employment. The crunch becomes a reality when hospital administration sees the pain points at the front end, with patients holding for a bed, and they attribute it to the back end, when they learn that patients are delayed from exiting because of limited post-discharge options and case management staff, who cannot seem to keep up with the new demands. 

Although the focus looks at the front and the back, and yes, both are important to consider, it is just as important to consider the progression of care in the middle. On top of this stress of patients leaving, we examine the length of stay, and there is nothing more stressful to administration then to learn that a patient has been in the hospital for 100+ days and they are just finding out about it. These patients are like neon signs, adding to the already compounding issues of regular throughput and discharge concerns. However, they are different; they are complex, and an outlier to the typical movement of patients in and patients out. Thus, they require special consideration and special attention. 

When evaluating metrics and length of stay/cost of care considerations (the great debate), recognize that complex cases should be separated from the herd. They will skew the data, and really should be treated and managed as a concern separate from regular throughput and cost efficiency issues.

Everyday Progression of Care

The everyday process of interdisciplinary rounds (IDR) or huddle is not complex case review. IDR is when a multidisciplinary team – ideally including case management, utilization review, a physician advisor or attending (depending on hospital configuration), and nursing, at minimum – quickly discusses patients on the unit to anticipate and gauge care needs, as it pertains to the progression of care towards discharge. Depending on the size of the unit and the location, additional team members may be helpful to include, such as physical therapy on the orthopedic units. Also consider pharmacy and dietary for ICU patients and medically complex units such as oncology. The complex residents of the hospital do not need to be discussed in this daily huddle unless there is any pressing news to report. There is not enough time, and the goal is to communicate the progression for all the patients who have not moved into the hospital.

Complex Case Review

Now, weekly, there is a bigger group that meets to discuss your complex patients. This meeting is typically an hour, depending on the size of the hospital. The name of this meeting, although often debated, really does not matter; it should be clearly understood, and the necessary people should show up prepared. Consider who is leading this meeting – likely it will fall to case management and the physician advisor. Invite stakeholders who will be helpful when quickly reviewing these cases and can escalate concerns and consider the hospital pocketbook for helping to get these patients out. The list for selection criteria can be individualized to the hospital’s needs. If you pull a standardized set of patients, such as patients with stays of greater than 10 days, or days 50 percent or greater than the geometric mean length of stay (GMLOS), be flexible and remember that you may need to adjust criteria to ensure that your discussion is meaningful and really focuses on the patients who require this level of review. Case management should also be coming to the meeting and highlighting patients who are still in the ICU and appropriately medically complex, although important information is not needed for this type of meeting. Also, those in the hospital who are under “outpatient in bed” or social admissions should be discussed immediately to ensure that the group is alerted early. We do not want to wait until these patients hit a report to start the conversation. Additional thought should also be given to discuss long length-of-stay observation patients if this is a growing concern.

As mentioned, case management is at the table, along with the physician advisor, utilization review, patient financial services, a therapy representative, and relevant nursing leadership. Also, a representative from behavioral health, risk, and/or the palliative care team should be on hand, if the hospital has these programs, as it may be beneficial. During the meeting, each person must understand their role. Each case should be presented concisely as to why the patient is still in the hospital, then a discussion of barriers and needed support from the team should ensue. This should be a dialogue with questions, not a report or an interrogation of the case manager.

During this meeting, there may be patients who require more time than the group has allotted. A clear leader of this meeting will need to call out to the group and say, “Let’s table this patient” or “This patient requires a separate care conference, and who should be involved?” These are the patients who may require involvement with the hospital’s legal team, outside resources, community agencies, the patient’s insurance provider, and/or family, if involved. Any hospital that wants to move these patients out will need dedicated time to discuss just this one patient. This is a separate meeting that requires dedicated attention and ability to review all options on the table. The hospital may even have to build that table!

The Complex Case Manager (CCM)

The CCM is of growing popularity to provide attention and connection to this patient population. The CCM is essentially a “super” case manager who has experience already working as a case manager in hospitals and has the right skill set and willingness to tackle just this population. They can provide the time to dedicate to this difficult caseload, and are able to build up relationships with outside agencies to help with such issues as guardianship, abuse concerns, or moving of assets to obtain long-term care benefits. The addition of the CCM can be huge to the department, to help take these patients off the rest of the case management team. However, this position is often developed from an internal candidate with the right skill set. It is very hard to fill externally, because finding someone to cover this population without knowledge of the appropriate resources is a larger lift, especially in the current job market. Additionally, this position is a hard sell from a compensation aspect, with hospital HR departments that do not have a benchmarking tool for this job description. It really requires some finesse to find the right person and have backing from leadership. However, if it works out, it is worth putting in place.  

The complex patient population is a growing concern in case management programs across the country, and the nuances of what to do require creative options, dedicated time, and much energy from a multitude of stakeholders, in the hospital and in the community. To ensure that metrics are not skewed, this population should be removed from the standard data set and live in its own subcategory to highlight the variations between the regular progression of care and resource utilization performance. As the marketplace continues to shift, patient complexity is not going to go away, and thus, hospitals must be willing to adapt. 

Programming Note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health every Monday on Monitor Mondays, 10 Eastern.


Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

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