Complex Care Management by Nursing Personnel

17 March 2021 Kalinga Institute of Nursing Sciences, KIIT (DU) 1

Complex Care Management by Nursing Personnel
Mr. Asokan R
Associate Professor
Kalinga Institute of Nursing Sciences
KIIT Deemed to be University
Bhubaneswar.

Outline
• What is Complex Care Management?
• What is complex patients & identification?
• Challenges of caring for the patient with multiple chronic
conditions
• GOAL
• Complex care team
• Essential elements of the role
17 March 2021 3
Kalinga Institute of Nursing Sciences, KIIT (DU)

What is Complex Care
Management?
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Complex Care Management (CCM) is a set of activities designed to
more effectively assist patients and their caregivers in managing medical
conditions and co-occurring psychosocial factors.
CCM is usually provided to patients who have serious medical needs and
often experience a high number of hospitalizations or emergency room visits.
The goal of CCM is to improve the patient’s health status and reduce the
need for hospital care.
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Complex care management is the deliberate organization of
patient care activities and sharing the information with the mail goal of
meeting patient’s needs and preferences in the delivery of high-
quality, high value health care.
(AHRQ - Agency for Healthcare Research and Quality, 2015)

GOAL:
To improve the quality and coordination of
care delivered to most complex patients.
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What is complex patients?
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Patients with multiple chronic conditions, frequent hospitalizations,
and limitations on their ability to perform basic daily functions due to
physical, mental and psychosocial challenges.
These health care issues could include brain damage, spinal cord
injuries, multiple sclerosis, muscular dystrophy, ventilators, Gastrostomy
feed needs such as PEG, Epilepsy, and learning disabilities.
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Example:
An 48 years old, overweight X was diagnosed with diabetes. Now 54, he has
added cardiac disease, renal insufficiency, and peripheral neuropathy to his
pathophysiologic conditions. In addition to multiple hospitalizations for evaluation and
intervention, X is a frequent visitor to the local emergency room for management of
acute symptoms. A data review of emergency department costs tags X as a problem.
X is a patient with complex disease-related care needs. He isn't very compliant
with prescribed care, continues to gain weight, and misses clinic appointments, all factors
contributing to advancing disease and compounding symptoms.
• Fulton, Janet S. The Future of Complex Care. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. July/August 2014, Volume
:28 Number 4 , page 195 - 196

Patient Identification
• Multiple admissions, readmissions, and emergency department (ED) visits
• Depression diagnosis
• Presence of actionable gaps in care: drug interactions, and absence of a
record of treatment or testing normally associated with a diagnosis
• Predictive modeling

High-risk patients are identified in several ways, including
Predictive modeling,
Monitoring of transactions and events,
New-member health risk assessments,
Referrals from physicians,
Patient meetings, and hospital inpatient
And ED reviews.
For predictive modeling, an algorithm is run to identify patients with chronic
or advanced illness.

Challenges of caring for the patient with multiple chronic
conditions
 Limited evidence base
• Complex, older patients excluded from trials, growing evidence of poorer
outcomes when treated according to disease-specific guidelines.
 Added care complexity
• Multiple guidelines, multiple registries, difficult co-morbidities such as psychiatric
disorders and substance abuse.
 Polypharmacy
 Multiple physicians and a poor care coordination culture and mechanisms.

Complex care team
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Complex care team:
 Nurse care management
Intensive case management
High risk patients
 Behavioral health consultants
Immediate consultations
Focused on outcomes
 Others members of the team
Clinical pharmacists
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Essential elements of
the role:
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Discharge:
Once goals are met, transition is complete, care plan is fully implemented
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• Person-centered
• Equitable
• Cross-sector
• Team-based
• Data-driven
Complex
care
seeks to
be:

Communication in complex care

• Good communication and coordination is very important between the
patient and the primary caregiver as well as between the caregiver and
specialists. This is particularly important during critical moments such as before
procedures, new treatments and trips to the emergency room.
• As an additional note, there is often not enough communication between
researchers and caregiver. Caregiver should try to relay important information
to researchers about management of both illness and patient care.
17 March 2021 21

Tips for caregivers
in complex care

Complex care program design

Program Design
1. Identify complex individuals
2. Establish a comprehensive care team workforce
3. Connect individuals to the comprehensive care team
4. Conduct person-centered assessment
5. Develop a care coordination care plan
6. Execute and monitor the care coordination care plan
7. Identify when individual is ready to transition to self-directed care maintenance
8. Monitor individuals to reconnect to comprehensive care team when needed
9. Evaluate the effectiveness of the intervention
17 March 2021 25

• Identify complex individuals
Using basic analytics to develop a risk stratification methodology, root cause
analysis - Relevant clinical data, Input from the complex individual sub-population.
• The network establishes a comprehensive care team workforce
Case management , Clinically focused care coordination , Community focused
care coordination , comprehensive care team
• Connect individuals to the comprehensive care team
During the primary care visit , During an ED visit or inpatient hospital stay, Pro-
actively reaching out to the individual

• Comprehensive care team conducts person-centered assessment
Preferred language
Family/social/cultural characteristics
Assessment of health literacy
Social determinant risks
Personal preferences, values, needs, and strengths
Assessment of behavioral health needs, inclusive of mental health, substance
abuse, and trauma
The primary and secondary clinical diagnoses that are most challenging for
the individual to manage

Develop a person-centered care coordination plan
Individual’s preferences and lifestyle goals, behavioral goals, social health goals
Execute and monitor care coordination plan
Protocols for regular comprehensive care team meetings
Identify when individual is ready to transition to self-directed care maintenance
Assess their readiness to independently self-manage, Peer Support resource
Monitor individuals to reconnect to comprehensive community care team when
needed
Mechanism to monitor transitioned individuals,
Evaluate the effectiveness of the intervention
Clinical outcome, individual care experience, and utilization measures,
improved performance

Complex Care Manager Nurse – Job Duties
• Acts as a primary source of care for patients
• Conduct clinical assessments over the phone to address the health and wellness
needs of patients using a set of clinical interviewing skills
• Develop care plans
• Communicates with the patients other care providers in more complex situations
requiring case management intervention.
• Serves as a subject matter expert to clinicians to provide education, consultation,
and training when needed
• Incorporates lifestyle improvement and prevention opportunities into member
interactions

Competencies, Skills, and Attributes:
• Excellent interpersonal skills and ability to work collaboratively
• Self-management skills, including ability to prioritize and set patient-
centered goals
• Excellent written and verbal communication
• Able to maintain professional boundaries
• Ability to work with diverse, safety-net population

• Skilled at engaging difficult to engage patients—build rapport, trust
• Creative problem solver
• Ability to adapt to changes in healthcare delivery at local and systems level
• Extensive knowledge of healthcare systems and community resources
• Ability to leverage systems and resources for improved patient outcomes
• Strong organizational and time management skills

Benefits
• ED and inpatient visits
• Total medical expense
• Patient satisfaction
• Clinical outcomes
• Provider satisfaction
• Avoidable admissions

Brian W. Powers, Farhad Modarai, Sandeep Palakodeti, Manisha Sharma, Nupur Mehta, Sachin H.
Jain, et al. Impact of Complex Care Management on Spending and Utilization for High-Need, High-
Cost Medicaid Patients. Am J Manag Care. 2020;26(2):e57-e63.
• A complex care management program for high-need, high-cost Medicaid patients
reduced total medical expenditures by 37% and inpatient utilization by 59%.
Based on the design of the program, these results suggest that:
• Carefully designed and targeted complex care management can be effective
among high-need, high-cost Medicaid patients.
• Community health workers and other nontraditional healthcare workers can help
engage and activate patients, build trust, and better understand and manage the
nonmedical drivers of poor health and avoidable spending.
• Targeted interventions focused on modifiable risk factors are an effective and
efficient approach for reducing unnecessary utilization.

David Blumenthal, et al. Tailoring Complex-Care Management, Coordination, and Integration for High-
Need, High-Cost Patients: A Vital Direction for Health and Health Care. Expert Voices in Health &
Health Care. 2016; 01-06.

Agency for Healthcare Research and Quality, U.S. Coordinating Care for Adults With Complex
Care Needs in the Patient-Centered Medical Home: Challenges and Solutions. January 2012
Patients who have complex health needs require both
medical and social services and support from a wide variety of
providers and caregivers, and the patient-centered medical home
(PCMH) offers a promising model for providing comprehensive,
coordinated care.

The key elements of complex care management:
Leadership, organization support, practice teams, and flexibility

• Humowiecki M, Kuruna T, Sax R, Hawthorne M, Hamblin A, Turner S, Mate K, Sevin C,
Cullen K. Blueprint for complex care: advancing the field of care for individuals with
complex health and social needs. www.nationalcomplex.care/blueprint. December 2018.

Complex Care Management by Nursing Personnel

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