While working for Mercy Health Saint Mary’s in Grand Rapids, Mich., Lauran Hardin, MSN, RN-BC, CNL, met one patient whose complex social issues and challenging life circumstances led to his frequent visits to the emergency room – not because he was injured or sick, but because he needed somewhere to go to feel safe. She realized that there is much more complexity to every patient than just their medical conditions, and healthcare providers can make a difference for these vulnerable people.
Five percent of the United States population accounts for 50 percent of healthcare spending, according to a recent report from the Agency for Healthcare Research and Quality (AHRQ). These complex patients can have expensive, high frequency access to the emergency room or hospital; often because of unmet health and social needs.
Instead of being primarily elderly patients with chronic conditions, as Lauran expected, many of these patients were under the age of 60 and struggling with psychosocial issues. These statistics drove Lauran, who currently serves as senior director of cross continuum transformation at the National Center for Complex Health and Social Needs, to create a model of intervention and a tool that gives providers an immediate and succinct overview of a patient, so the doctor or nurse can provide the most comprehensive care possible during the patient’s time in the facility.
Because of her background in process improvement and strategic planning, Lauran was tasked with looking deeper into the stories of these patients, where she found that many details were lost in medical records and there was limited consistency of care across the various facilities these patients frequented. She recognized the importance of creating a comprehensive patient story, which included all forms of care and potential social and behavioral root causes.
“We’re used to looking at patients acutely in the moment, but we need to start seeing patients across the continuum of care and understand their complete stories,” Lauran said. “There’s a universal need to understand a broader patient story and have that information available in the moment of care.”
As a nurse, Lauran was in a unique position to look broadly at what patients need and to understand how to link people together to create interprofessional teams that provide a higher level of care. This perspective led to the creation of the Complex Care Map, a cross-continuum tool that helps providers view a root-cause analysis for complex patients and ultimately provide more comprehensive care for them.
Once the Mercy Health team developed the tool, the work received attention from Trinity Health, a national health system operating 94 hospitals in 22 states, which began to implement it across their network. After an article about the Complex Care Map was published, several hospitals began working to pilot their own versions of the program and start bringing more comprehensive and culturally competent care to patients across the country.
“Being aware of these social determinants of health when caring for patients is becoming more important and is something providers need to keep in mind,” Lauran said. “Making these changes in the care provided can result in improved outcomes for patients, providers, and the healthcare system overall.”