Complex Care Center
Background & Goal
High frequency and complex patients struggle with the silos that exist in the payment system and in the specialized healthcare
delivery system. The complexity of their health problems and/or psychosocial needs make them high utilizers of Emergency
Departments (ED) and inpatient services. As the Robert Wood Johnson Foundation reports, 5% of the population uses 60% of all
healthcare resource dollars (http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2012/10/robert-woodjohnson-foundation-awards--2-1-million-in-grants-to-0.html). Success in population health and a shift to ACOs require a robust
strategy for high frequency/high cost patients.
The Complex Care Center began in February 2012 as a quality improvement and safety initiative for high frequency and complex
patients in the Clinically Integrated Network at Mercy Health Saint Mary's in Grand Rapids, MI, part of the Trinity Health system.
A Model of intervention was created to stabilize complex patients by mentoring and maximizing existing resources in their circle
of care. Building a community of consistency and safety around the complex patient population has been one of the key drivers of
the change in outcomes. Linking providers in a shared plan of care decreases fragmentation and establishes a solid foundation.
Addressing social determinants of health (housing, transportation, financial barriers, or mental health/trauma) as part of the
shared plan adds to the foundation.
The Complex Care Center’s ‘population approach’ for high frequency and complex patients is an innovative nursing model of care
coordination that operates as a facilitator and change agent, rather than a new case manager, clinic, or revenue source. The
Center is focused on changing the system, rather than primarily trying to change the patient, and occurs whether the patient
engages or not. The approach is inherently interdisciplinary and creates collaboration across systems and disciplines, rather
than displacement, to improve patient outcomes.
Lauran Hardin, MSN, RN-BC, CNL
In addition to patient intervention, the Center provides three other services to extend the effect: business intelligence, process
improvement and population intervention. Annual reporting on the high frequency population (regardless of payer) including potential root cause drivers and
subpopulations with financial impact is provided for the Clinically Integrated Network.
Project Description
The five key aspects of the Complex Care Center’s model include: 1) a 10 year analysis of the medical record to capture the full patient story and identify root
causes of frequency/complexity, 2) conferences for care management providers across the continuum of care (regardless of health system affiliation), 3) a shared
evidence based plan (Complex Care Map) to change system response 4) embedding the plan in the medical record, 4) following the patient on every admission,
and 5) readdressing the plan in iterations. Once referred, patients are followed for life and the Center re-engages the process as needed on every subsequent
admission and emergency visit.
The Complex Care Center links providers into a community of support around the patient. For example, if the patient is frequently admitted for disease
management, he or she is assigned to the same unit and team to increase consistency of care. Using a tool built into the Emergency Medical Records to house the
shared plan, an alert pops up the first time a provider opens the record for each ED visit, increasing the consistency of the ED care. Included in the process are
reminders to hospital staff to link with the cross continuum team members managing the patient outside of the hospital, which reinforces the community of
support around the patient. When the Complex Care Center’s analysis reveals a patient has ties with resources in the community other than with his or her
primary care provider, the Complex Care Center facilitates formal relationships with these agencies to collaborate in the overall care and well-being of the patient.
Evidence of Success
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For More Information, Please Contact:
Population of 210 Complex Care Center patients 12 months out from initial intervention experienced
the following changes in accessing the healthcare system:
o 61% decrease in inpatient/observation admission
Lauran Hardin MSN, RN-BC, CNL
o 61% decrease in length of stay
Director Complex Care
o 39% decrease in ED/urgent care visits
Mercy Health
Total gross charges attributed to the same population of 210 Complex Care Center patients 12 months
200 Jefferson SE
out from initial intervention decreased from $11.5 million pre-intervention to $4.4 million postGrand Rapids MI 49505
intervention.
(616)685-5253
Total direct expenses attributed to the same population of 210 Complex Care Center patients 12
hardinlj@mercyhealth.com
months out from initial intervention decreased from $3.3 million pre-intervention to $1.1 million postlauran@octoberday.com
intervention.
Total contribution margin attributed to the same population of 210 Complex Care Center patients 12 months out from initial intervention increased 50%
per case post-intervention.
In FY 2014, uninsured visits decreased 63% and unreimbursed care decreased $1 million for Complex Care Center patients (n=750).
This project was undertaken as a Clinical Quality Improvement Initiative at Mercy Health, and as such was not formally supervised by the Mercy Health
Institutional Review Board per their policies.
About Raise the Voice
Through Raise the Voice, the American Academy of Nursing is mobilizing its 2,200 fellows, partner organizations and health leaders to ensure that Americans hear
and understand the exciting possibilities for transforming the health system – and also that they see how nurses are leading the way. For more information about
this Edge Runner and others, please visit www.AANnet.org.