From the Executive Editor

Complex Patients with Complex Discharge Needs: The Continuing Challenge

Catherine M. Mullahy

As I contemplated, during this very busy time of year, just what to address in this last issue of CareManagement for 2022 and the first issue for 2023, it occurred to me that there is a continuing problem facing some of our patients and their case managers. It has become an accepted belief that not every patient needs a case manager. Surely those with seemingly insurmountable problems and issues that impact their care require more than what may still be the “norm” in our healthcare system.

We’ve done a great job using data analysis, predictive modeling, and other metrics to identify the kinds of patients that would benefit most from a professional case manager’s intervention and care. We have achieved some success in identifying individuals who are sometimes called “frequent flyers” or “high utilizers.” The most common reasons for hospital readmissions have been determined to be disengagement and noncompliance, condition complications, inadequate transition of care, misinterpretation of discharge instructions, and demographic factors. We have created programs that have greatly reduced the rate of hospital readmissions and length of stay for conditions that are most problematic (e.g., sepsis, congestive heart failure, kidney disease, chronic obstructive pulmonary disease, diabetes). It would seem, however, that as soon as some success is achieved, we need to turn our attention to other matters. Given that the number of complex patients with complex needs are increasing, it might be time to reexamine key factors relating to the case manager’s involvement in treating complex patients. For instance, should we reconsider the duration of contact from a case manager, the frequency of that involvement, and the types or components of the case management process that are most effective? I believe we should.

As hospitals and case management leaders all across the country

were creating the Hospital Reduction Readmission Programs (HRRP) to address conditions most responsible for hospital readmissions (e.g., septicemia, heart failure, diabetes with complications, and chronic obstructive pulmonary disease) (Overview of Clinical Conditions With Frequent and Costly Hospital Readmissions by Payer, 2018 #278 (ahrq.gov), there was increasing recognition of the need to expand the preparation and education of case managers. The number of individuals obtaining and pursing their CCM (certified case manager) certification and continuing education has increased. As of March 2022, that figure reached 50,000. These are the true hallmarks of professional accountability and the growing evidence of the importance of our role across the health care continuum. There has been significant progress in avoiding hospital readmissions and the subsequent complications that patients experience, not to mention the costs incurred. Now, however, we must examine just how we are accomplishing those goals. Are there components of the process that are more valuable than others? Does every patient need the same kind of intervention? We recognize the need to adhere to the core components of the process, with advocacy at its heart and center, but we also need to periodically examine the effectiveness of that process. Of significance, in the last several years an integrated case management model has emerged that incorporates the behavioral health and social determinants of health components of patients and their caregivers, along with their medical problems. This model has resulted in a more comprehensive and inclusive process with favorable results.

Our patients, however, continue to experience problems. They are confused about their discharge and treatment instructions, their physicians and other members of their care team don’t communicate and coordinate their care, they don’t adhere to prescribed treatment and medications, and they are resistant to recommended lifestyle changes. In addition, they experience growing dissatisfaction and frustration with the quality of care they are receiving, the medical errors that are occurring, and the overwhelming number of providers and settings that are involved in their care.

It’s no small wonder that our patients and case management colleagues are continually frustrated. If we’re working so hard, why are the problems continuing and how can we

Given that the number of complex patients with complex needs are increasing, it might be time to reexamine key factors relating to the case manager’s involvement in treating complex patients.

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