Complex Care Center

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 ( 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.

For More Information Contact:

Lauran Hardin MSN, RN-BC, CNL

Director Cross Continuum Transformation
National Center for Complex Health and Social Needs
Camden Coalition of Healthcare Providers
800 Cooper St, 7th Floor 
Camden, NJ 08102
(856) 365-9510
(616) 802-7825

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.  Using a tool built into the Electronic Health Record to house the shared plan, an alert pops up the first time a provider opens the record for each ED or Inpatient visit, increasing the consistency of the 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.  Complex Care Maps have rolled out to 25 Hospitals in the Trinity Health system and are in the process of being implemented as a standard of best practice care for all EDs in Trinity Health (92 hospitals, 22 States).

Evidence of Success

  • Population of 661 Complex Care Center patients 12 months out from initial intervention experienced the following changes in access to the healthcare system:
    • 34 % decrease in inpatient/observation admission
    • 26 % decrease in length of stay
    • 35 % decrease in ED/urgent care visits
  • The decrease in loss from unreimbursed care from Complex Care Center patients in FY 2015 was $492,728 for inpatients and $1,145,885 for outpatients.
  • Total direct expenses attributed to the same population of 661 Complex Care Center patients 12 months out from initial intervention decreased from $7.1 million pre-intervention to $4.2 million post-intervention.
  • Total operating margin attributed to the same population of 661 Complex Care Center patients 12 months out from initial intervention improved $773,000.

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.