Among the range of groups whose care sucks up a disproportionate amount of healthcare resources, “Complex Care Patients” present a special challenge for hospital leaders seeking to improve their hospital’s capacity management. These patients require special processes and a deliberate strategy to ensure that their hospital stay isn’t prolonged further than necessary. Failure to address complex care patients directly will have an adverse impact on hospital capacity management.
If a 300 bed hospital has 5 percent of its patient population with a length of stay (LOS) of more than 20 days, for example, those 15 patients will essentially utilize the equivalent number of bed days as 75 patients who stayed in the hospital for four days.
Setting the Threshold for Review
The threshold set by hospitals to review lengths of stay varies based on institution and the types of patients served. Small hospitals without significant subspecialty support for such things like dialysis, long term respiratory care or even psychiatric care can often set a lower threshold for length of stay and subsequent intervention by transferring patients to higher acuity facilities. Tertiary care facilities may have a more challenging patient population to manage. These facilities are often the recipient of long term complex care patients from smaller hospitals.
Regardless of size, though, every hospital should consistently manage and review patients whose LOS has become extended for whatever reason. Many hospitals have a defined a list of patients who have been there for an extended period. This list may include patients admitted more than 30 days ago or perhaps 25 or 20 days. Some hospitals set the threshold as low as 7 days.
Complex Care Patient Types
Many complex care patients have more than one issue or multiple obstacles to overcome before arriving at a strategy for care, either to continue to treat or to transfer to another facility. One example would be a bariatric chronic vent patient on hemodialysis with osteomyelitis – but the list of conditions is long. These include patients with certain respiratory conditions, certain nephrology or infectious disease patients, patients with specialty equipment needs, certain psychiatric patients, and in some cases patients with either legal guardianship or end of life issues.
Strategies for Complex Care Capacity Management
Regardless of the volume of patients, every hospital should have a system and team to review these patients and develop a plan for them if necessary. The challenges surrounding this complex patient population can be daunting. Hospitals can employ a number of strategies to manage this complex patient population:
- Provide long-term care within the acute care facility
- Transfer the patient to an alternative hospital due to extenuating care delivery circumstances
- Build or modify an existing long term care facility to provide the necessary long term acute care needs to transfer the patient from the acute care hospital
- Institute agreements with long term care facilities to accommodate the complex care patient population
The Complex Care Team
Whatever strategies are used to manage these patients, a coordinated team effort is required to daily review and update treatment plans and alternative care options. This team is ideally composed of the following:
- Physician leadership
- Care management representation from each med/surg/psych unit
- Infectious disease representation
- Representatives from long term care facilities
- Palliative Care
- Administration representative
This group should meet weekly to identify all complex care patients exceeding defined LOS thresholds and associated treatment plans for each patient. As focus and resources are directed toward this group of challenging patients, there needs to be continued emphasis on reducing the LOS threshold to provide continuous improvement and a team approach to patient disposition.
Complex care management should also involve daily rounding by the physician champion on the various units with care management to determine barriers to patient disposition. This type of pro-active management can provide earlier assistance in the use of consultation such as palliative care intervention.
More Efficient Care
This type of daily and weekly multi-pronged team approach to identification and disposition of this patient population can have significant impact on hospital capacity. Reducing the LOS of this population can have a positive impact on every aspect of hospital capacity management, reducing bottlenecks, making more efficient use of the beds that are available, and ultimately improving patient satisfaction. Few patients want to stay in the hospital longer than absolutely necessary, after all.