1 of 6 COMPLEX CARE POLICY 1. Purpose The purpose of this policy to is to assure that patients with complex needs impacting their health status will receive standard services across the continuum of care to achieve optimal outcomes to the problems identified. 2. Policy The Hawaii Region recognizes that events and conditions in the lives of patients impact the ability to effectively cope with and manage their health. Patients with serious and complex medical conditions will be identified, assessed, treated and monitored to ensure delivery of timely, integrated and coordinated health care services that correspond with the appropriate levels and types of medical, behavioral, social and health services required. Each patient identified shall have a care coordinator designated to oversee the care processes required. Registered nurses with case management training provide general care coordination services. Specialty care coordinators are utilized for various special populations. 3. Scope This policy applies to all entities, departments and staff of the KP Hawaii Region. 4. Standards 4.1. Identify patients with serious and complex medical conditions Clinical information systems are used to the extent practicable to identify patients with serious and complex medical conditions. 4.1.1. Tools for identification of affected patients include, but are not limited to: a. questionnaires, b. survey instruments,and c. practitioner assessment.
2 of 6 4.1.2. Patients identified with serious and complex medical conditions shall be referred for assessment by a practitioner or care coordinator to further determine the need for care management. Current serious and complex medical conditions for which care coordination services are available include patients with; Asthma Certain behavioral disorders Congestive heart failure Coronary artery disease Diabetes Or who are: Frail elderly HIV infected On anticoagulants Tobacco product users Perinatal substance users 4.2. Assess the medical, behavioral, social, and other health care needs of the patient. The assessment: shall determine service needs, shall be conducted by a practitioner or a care coordinator, shall include appropriate physical, behavioral, and social parameters, may occur at any point on the health care continuum, shall be initiated upon identification of chronic condition or complex medical condition, may be conducted in person, via questionnaire, or using telecommunication technology, and shall include relevant data from the patients, family members, caregivers, practitioners and others involved in the care. 4.3. Identify the needs of the patient 4.3.1 Assessment results shall be used to delineate the patient s medical, behavioral, social and other health needs vis-à-vis the complex health problem(s).
3 of 6 4.3.2 The identified needs shall be communicated to the Primary Care Physician and other practitioners and staff coordinating the patient s care. 4.4. Develop a treatment plan to address the service needs identified 4.4.1 The care coordinator shall develop a treatment plan, in consultation with the Primary Care Physician/authorized practitioner, the patient and family member or designated caregiver and representative, and other members of the various services involved in the care. 4.4.2 The treatment goals shall reflect the service needs identified in the assessment process. As appropriate, intensive chronic disease management guidelines approved by the Quality Council shall be applied and customized to meet the specific needs of the individual patient. The Primary Care Physician/authorized practitioner shall approve modification of medical treatment plans. Patients with serious and complex medical conditions not covered by a population management guideline shall have individualized treatment plans developed that specify treatment goals, required primary care and specialty medical services, and appropriate behavioral health and social services. Each plan shall establish the period of time covered by the treatment plan, monitoring parameters and reassessment dates. Team conferences may be called, as needed, to develop the treatment plan with multiple complex medical, behavioral, and social needs requiring multidisciplinary coordination. Family members shall be included in team conferences, as appropriate. Contract services via Affiliated Care Department shall be utilized as appropriate for services covered by the patient s benefit package. Referrals to external agencies in the community shall be made for those service needs not covered as benefit. 4.5. Implement the treatment plan 4.5.1 The care coordinator and Primary Care Physician/authorized practitioner are jointly accountable to assure that the treatment plan is implemented according to design.
4 of 6 4.5.2 The RN working with the Primary Care Physician is considered the care coordinator unless another care coordinator has been determined. a. Coordination of the services planned, whether internal or external to the organization, is the responsibility of the care coordinator. The care coordinator shall: facilitate the referral to practitioners, consultants, specialists and other service providers, track the patient s progress, and facilitate communication and information exchange between the members of the health care team. 4.6. Monitor, evaluate, and modify treatment plan 4.6.1 Periodically, as specified in the treatment plan and more often if needed, the care coordinator shall reassess the patient s status to determine progress toward accomplishing the goals stated in the treatment plan. 4.6.2 Reassessment information shall be utilized to modify the treatment plan, as appropriate. 5. Definitions Care coordinator: generic term used in reference to the professional and licensed staff member who manages and coordinates all health care services for the patient. This includes case managers, care managers, coordinators, and other staff authorized and qualified to coordinate all aspects of patient care. The term excludes staff members who provide limited monitoring and management of one or two aspects of care. Complex Care: process of planning and delivering care for individual patient or patient population with one or more serious and complex medical conditions, that are persistent and substantially disabling or life threatening and require treatment and services across a variety of domains of care to ensure the best possible outcome. 6. Responsibilities Quality Council has oversight responsibility for this policy. It also has the responsibility for determining the member populations for which special intensive management programs shall be established in consultation with primary care physicians and physician leaders of complex care programs and the Institute of Medicine guidelines.
5 of 6 Each disease management team has the responsibility for developing treatment guidelines that take into account our patients medical, behavioral and social needs. Clinic Administration and Hospital Administration are jointly responsible to administer the policy and develop relevant processes to coordinate the implementation of the policy. The Affiliated Care Department shall assure the implementation of this policy within affiliated care providers and other contracted care settings. 7. Maintenance This policy shall be reviewed annually and revised or updated as necessary. 8. References Centers for Medicare & Medicaid Services. 63 Federal Register Part 422 [ 422.112(a)(1)(iii)(B)]. National Committee for Quality Assurance (NCQA). Medical Directors Quality Review (MDQR) Continuity of Care Standard A.5; A.6. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Institute of Medicine Definition of Serious and Complex Medical Conditions, National Academy Press, 1999. 9. Implementation This policy is effective upon approval by the approving authorities. Affected care teams and administrative departments shall adjust or develop care processes and procedures to be consistent with this policy. Appropriate education shall be conducted to assure uniform and consistent implementation of this policy throughout the region.
6 of 6 10. Review and Approval Authors: Olivia Castro, RNC, MS, MPH Director, Ambulatory Nursing Practice and Population Management Date: 05/2000 Endorsements: Quality Information Team Hospital Management Team Date: 06/2000 Approved By: Quality Council Date: 06/14/00 Hospital Executive Committee Date: 06/21/00 Reviewed: August 2003 Next Review: August 2004