Patients with chronic and progressive illnesses are vulnerable to long length of stays (LOS) and readmission. Often, these readmissions reflect fragmentation of health care and poor transitions of care leading to substandard patient outcomes and higher health care costs. In our hospital medicine practice, only a small percentage of patients have an extended LOS greater than 15 days, but they account for over 50% of excess days. In addition, patients with long LOS are subject to more physician handoffs than those who have short stays, further fragmenting care. Providing for these patients is time and resource intensive, distracting hospitalists and other staff from caring for the many others on their census.
We set out to establish and assess the effects of early intervention by a multidisciplinary care team on the management and outcomes of patients with complex and advanced illness. The team was designed to establish continuity and consistency of care and to facilitate optimal transitions of care at the time of discharge.
We organized a multidisciplinary team (senior hospitalist, nurse practitioner, RN case manager, social worker) around 3 ideas: (1) Team members were chosen for their experience and skills, (2) team members remained on service for two months at a time to minimize handoffs and allow for optimal team development, (3) the team census was kept low to allow sufficient time for patients, families and for coordination of care. This team served as the patient’s primary care team irrespective of location in the hospital. Patients were identified and care was assumed by the team based on (1) 3 or more readmissions within a 6 month period, (2) LOS ≥ 15 days, (3) anticipated LOS ≥ 15 days. Additionally, the team would assume care if any patients were readmitted. Family meetings played a central role in delivery of information and establishing goals of care. All post discharge care (home care, appointments and transportation) were arranged. Inherent within this identified population were patients with challenging medical issues, diverse social and familial relationships, as well as insurance and or financial limitations. By working closely together, the team was able to provide timely and effective communication to the patients, families, consultants and outpatient primary care doctors. More than half of these patients were recruited from busy housestaff teams where the necessary attention and resources were not being provided. By assuming care, the team was able to address issues promptly and organize optimal care and discharge plans. Furthermore, by shifting these patients from housestaff and hospitalist teams, those teams could increase their own patient volume and throughput.
Improving care of chronically ill patients demands attention not just to the hospital course and immediate post discharge period, but to the care system in its entirety. It is a daunting task, but a necessary one, if as hospitalists, we aspire to provide measurable quality improvement in care for our patients.
To cite this abstract:Loukas E, Ahmad S, Khan M. A Multidisciplinary Approach to Treating Hospitalized Complex Patients: Does This Have Value?. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 253. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/a-multidisciplinary-approach-to-treating-hospitalized-complex-patients-does-this-have-value/. Accessed April 1, 2020.