Orchestrating complex care

Categories: Care.

Every hospice faces patients whose needs are beyond our usual parameters—patients who require “complex care.” Consider, for example, the newborn with multiple anomalies or the ALS patient on BiPAP. Or perhaps a patient who is experiencing ventilator withdrawal or another who has attempted suicide. The next obvious question is what should we be doing differently?

At Chapters Health System, which operates LifePath Hospice in Temple Terrace, FL and Good Shepherd Hospice in Sebring, FL, we have established a formal process to better serve these patients and their families. This process, which we refer to as our “Complex Case Format,” helps us coordinate the multiple priorities, ensure maximum communication among staff at all levels, and provide flexibility to adapt, depending on the patient and family’s current needs.

In this post (read the full article online), we review the steps involved in the Complex Case Format.

The Complex Case Format

There are four primary steps in this process. The following sections will identify the objective and process for each step and how each step in the complex case format relate to one another.

Step 1 – Gather Information

Obtain the past and current medical information about the patient, but also identify family dynamics, the decision-makers, caregivers and spokesperson, as well as what the patient and the family expects and wants.

Step 2 – Inform All Involved

Advise the patient and family of what to expect from us, including time-frames and specifics such as the name and phone number of their hospice contact person. It’s also equally important to make sure that all staff who will be providing the care have the pertinent information about the patient and family.

Step 3 – Conduct a Complex Case Conference

 Oftentimes conducted as a conference call, this meeting should present and discuss the case, and ultimately determine if the hospice should admit or not admit the patient to service. Thus, it’s essential that all necessary parties take part in the meeting, such as the certifying physician; MD or ARNP who will be attending the patient; RN who has been coordinating the admission; social worker and/or chaplain; the admissions manager; manager of the receiving team and/or designee; and any specialty staff (e.g., a respiratory or infusion therapist).

Step 4 – Debrief

After the high-intensity portion of the patient’s care is accomplished, have the same people who participated in the conference reconvene to assess and identify what went well and what changes might be needed in future complex cases.

Benefits of the Complex Case Format

By including all of the players in the discussion—patient, family and staff—everyone understands what is expected, each other’s role and function, and how the pieces work together. This level of coordination helps to reduce anxiety and empowers staff to make wise decisions. The process itself can be likened to that of an orchestra, where planning and communication ensure a harmonious outcome. Of course, the demands and available resources for each hospice may be quite different, so this format is really only meant to be a starting point for your organization, not a “one size fits all” solution.


Leslie Szasz is a senior nurse preceptor at Chapters Health System, with 38 years of healthcare experience. In her current role, she provides both classroom and in-home training for team preceptors and staff. Janis Tucci has worked in the field of nursing for 45 years. She joined LifePath Hospice in 2008, and has served as the manager of Melech Hospice House since 2009.

This feature is an excerpt from an article that was originally featured in NHPCO’s June 2013 Newsline.


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