April 17, 2014

Team coordinates care for patients with many needs

When Eddie Dotson arrived at Vanderbilt University Medical Center last September, he weighed 627 pounds and truly embodied the label “morbidly obese.” He had so much fluid in his chest it was hard to breathe and his heart, liver and kidneys were failing.

When Eddie Dotson arrived at Vanderbilt University Medical Center last September, he weighed 627 pounds and truly embodied the label “morbidly obese.” He had so much fluid in his chest it was hard to breathe and his heart, liver and kidneys were failing.

Through sheer determination, and with the help of Vanderbilt’s Complex Care Team, Eddie Dotson lost more than 300 pounds and dramatically improved his failing health. (photo by Joe Howell)

Dotson, 40, from Pegram, Tenn., loved to ride motorcycles but had gotten so heavy he was basically confined to his bedroom. His sister, Veronica, had taken him to the hospital but wasn’t able to care for him at home, and he faced spending the rest of his life in bed in an assisted living facility.

Then Vanderbilt’s Complex Care Team got involved. The new service is charged with caring for patients with complex needs — medically, socially and economically. Complex patients may have multiple disease processes or be homeless, undocumented or uninsured. Many also have mental illness.

“It’s about bringing creative solutions to solve the issues of highly complex patients. We’re concentrating the complex patients into the hands of a small team of providers with expertise with this population,” said John Morris, M.D., associate chief of staff for the Vanderbilt Health System.

When Eddie Dotson came to Vanderbilt last September, he weighed 627 pounds and was near death. With the help of the Complex Care Team he’s now down to 270 pounds.

Currently, the Complex Care Team consists of a nurse practitioner, case manager, social worker and financial counselor. There are plans to add a pharmacist, and the team will expand as needs emerge.

“This is one of the first opportunities to carve out a population of patients and care for them differently. The complex patients all sit on different units but are under the same care team,” said Beth Anctil, MSN, administrative director of Transition Management.

There’s the immigrant from Jordan who had been hit by a car and needed to recuperate with family in his homeland, but had an expired passport. The Complex Care Team did the documentation paperwork and arranged a medical escort for his flight home. There’s also the dialysis patient who has been banned from local outpatient dialysis centers for disruptive behavior, and the patient who is ready to be discharged but has no home to go to.

In Dotson’s case, the Complex Care Team knew he was committed to losing weight and secured a scholarship for him to spend a month at Vanderbilt Stallworth Rehabilitation Hospital with the help of Juan Cabrera, M.D., assistant professor of Physical Medicine and Rehabilitation.

“In the hospital they said I was six hours from death and they didn’t know if they could save me. I saw the writing on the wall. I had seen it before and just didn’t listen, but I knew I had to lose weight this time,” Dotson recalled.

The Complex Care Team includes, from left, nurse practitioner Cherry Chassan, DNP, R.N., financial counselor Phyllis Greene, case manager Tanya Parrish, R.N., and social worker Josh Owens, LMSW. (photo by Susan Urmy)

“September 24 was the first time I stood up for a few seconds. It tickled me to death and I never looked back.”

Dotson left Stallworth a month later at 392 pounds, walking under his own power with just a cane. Today, he is at 269 pounds. He visits the YMCA every day for cardio and weightlifting.

“The first thing everyone asks when they see me is what surgery I had. They think you have to have surgery to lose that much weight, but you don’t. You just have to have the willpower and good people to help you out.”

The Complex Care Team’s nurse practitioner, Cherry Chassan, DNP, R.N., said Dotson’s case embodies the team’s patient-centered focus. Instead of simply discharging Dotson to assisted living, they learned he was motivated to lose weight and fought to get him into Stallworth, where he would have the resources he needed to succeed.

“The stories are very sad and the cases can be very hard, but we strive to do the best we can do,” Chassan said. “We listen to what the patient’s goals are and have to keep that at the forefront, even in complex cases.”

About 18 months ago Morris began tracking complex patients — defined as those staying more than 21 days in the hospital — and identified patterns in their disease processes and social situations.

“In the past, we dealt with complex patients on a floor level via case managers. The problem is that a complex patient takes so much time and effort that it hinders the efficient case management of the standard patients. Every complex patient was managed as a one-time event because they were distributed across the enterprise. Now, with the complex care team, we can recognize patterns and design system-wide solutions,” Morris said.

Among patients staying more than 21 days, Morris figures excess days in the hospital were reduced by about 5,200.

“With this proof of concept, we are expanding the population that the care team is going to look at to be able to include patients with previous history of high resource utilization. If they meet certain criteria day 1, they will be flagged so the care team can begin following them,” Morris said.

Providers may also request a Complex Care Team consult through WizOrder.

An important piece of the team is the participation of the Center for Biomedical Ethics and Society.

“Many patients are complex because it’s not clear what the right thing is to do for them. There can be a lot of confusion with the patient’s wishes versus the family’s wishes, or the primary care team may have concerns or reservations about the right thing to do.

“Bringing Biomedical Ethics into the discussions allows us to get a much clearer pathway forward for patients,” Morris said.

The center’s director, Keith Meador, M.D., said most people think of an ethics consult when there is an end-of-life dilemma, but it should be involved much sooner.

“Ethical challenges are frequently psycho-social, maybe involving family dynamics or living situation, or who are the best surrogates for helping make decisions,” Meador said.

“We often talk about goals of care — what is the patient hoping for? What do they see as thoughtful consideration of what they want and expect as outcomes? Sometimes we think we know what patients want, but we really haven’t listened. This is an intentional gathering of hopes and expectations of patients, families and the health care team.”

The Complex Care Team is now working to affiliate with community partners to give patients more options for resources and assistance. It is also developing a “virtual care team” to follow complex patients outside the hospital to ensure the care plan is executed.

“It can make sure patients are getting to their follow-up appointments, home health is set up and they’re getting their medications. As the complex team grows and we care for more patients, we want to be able to follow them across the continuum of care,” Anctil said.

Dotson has his sights set on a goal weight of 200, and then he will buy the fancy suit he’s always wanted to wear. He clearly believes he would be dead without the Complex Care Team and Stallworth staff.

“It was unbelievable how quick they got me on my feet. It’s all in how bad you want it and having people to help you get there.”