NUBE 2024

As one of two healthcare systems within a Midwest city, Summa Health struggled to maintain continuity of care across encounters. The same individual seeking care for the same chief complaint might receive vastly different treatment based upon the clinicians caring for them from encounter to encounter. Furthermore, each encounter was treated by clinicians as a stand-alone interaction. Clinicians might “chart review” what had been done at a prior encounter, but there was no mechanism to share a comprehensive understanding an individual’s goals, needs, and challenges. Additionally, no structured way to incorporate community-based interventions into hospital-based care existed – patients effectively were “discharged” to find their way. As a result, the same patients with the same challenges were treated over and over with little forward progress made.

Among front-line clinicians of all varieties, this status quo was a source of frustration. Collaborating on care plans was time-consuming and ad hoc. Thus, Summa Health Department of Psychiatry developed a Complex Patient Treatment Planning Committee, involving clinicians from multiple disciplines and specialties to collaborate in the development of Complex Treatment Plans for a subset of individual patients who were not being well-served with an ad hoc process. A registry of patients was developed, multidisciplinary treatment plans were developed and vetted by experts across a variety of settings, and these plans were shared across the system and the community to support a unified approach to help individuals meet their goals.

As a result of this Committee, individual clinicians were supported in their care of these complex patients with a robust treatment plan that crossed between encounters and organizational boundaries, improving patient care and reducing clinician frustration.

Learning Objectives:

To describe the challenges of caring for complex patients within a fragmented healthcare system.

To provide an example of one approach to complex treatment planning within a healthcare system and community.

To examine the factors that may contribute to success for a multidisciplinary team approach to increasing continuity of care for behavioral health patients.