C O L L A B O R A T I V E C A SE M A N A G E M EN T

A Medical Director’s Perspective

A Consistent Approach to Quality Care:
Examining an Effective Care Plan Model for Complex Patients
Neena Reddy, MD, and Ann Kostial, RN, BS, MHA

In virtually every organization there are patients who can be classified as ‘challenging’ to the care process. Characteristics of such patients
may include: frequent use of acute care services; a history of non-compliance; a history of narcotic seeking behavior; a history of psychiatric
diagnoses; or those with questionable secondary gain. In order to adequately care for these types of patients and discourage any negative
behavior or patterns, special considerations must be made.

In July 2009, University of Pittsburgh Medical Center Presbyterian
(UPMC Presbyterian) implemented a physician-driven initiative to
develop care plans for those patients classified as challenging. This
article examines an innovative model for patient care and its benefits
to both the care team and the patient.
Identifying Challenging Patients
At UPMC Presbyterian, a challenging patient can best be described as
any patient who frequently utilizes services in the acute care setting
including the emergency department (ED), as well as ongoing and
frequent utilization of acute care services in inpatient status.
Many of the patients who frequently, and often unnecessarily, utilize
hospital resources display non-compliant behaviors. For example, a
patient may present at the ED with an issue that could be more
appropriately addressed by their primary care physician (PCP). Other
examples of non-compliant behavior may include a patient coming to the
ED seeking pain medications or a dialysis patient who visits the ED
because they simply choose not to follow-up with their scheduled dialysis.
System for placing Patients
At UPMC Presbyterian, patients who benefit from a specialized
care plan can be identified in a number of different ways. Moreover,
the primary means for identifying said patients is through a
specialized set of criteria which analyzes ED usages and the acute
care setting admissions (see figure A). The criteria also takes into
account the patient’s number of readmissions, previously identified
behavioral issues and/or narcotic seeking behavior. Care plans are
integrated into the organization’s electronic health record (EHR),
which aids in the identification process as a patient’s history can be
quickly accessed in order to retrieve data.
Additionally, patients in need of complex care plans are often
identified through physician referrals. For instance, if a physician
feels that a particular patient could benefit from a care plan because
they are continuously being seen in the ED, and they are persistently
non-complaint with respect to their current plan of care, a specialized
care plan can be developed based on the physician’s
recommendations. Similarly, plans are often developed via social
work and care management referrals.
A stratification tool is also employed which allows the care team
to prioritize patients when developing individual care plans. For
example, if there are 50 patients in need of a care plan, this

in the queue for development

1. Number of readmissions in last
six months:
a. <6 = 2 c. >10 = 5
b. 6-10 = 3
2. Narcotic seeking
a. No = 1 b. Yes = 5
stratification tool allows the care team to revise the patient order to
immediately create a care plan for those whose needs are the most
urgent. Through this “triage” system, a patient in the top 10 may be
relegated to a lower level of priority for a care plan if his or her needs
are not as critical.

3. Health Plan Member 4. Behavioral Issues during AD

a. No = 1 b. Yes = 5 visits or admissions
a. None = 1 c. Moderate = 3
b. Mild = 2 d. Severe/resource
intensive = 5
5. Number of ED visits in last 6 6. Unusual care needs (e.g., vent
months dependent, quad, complex and
a. Scaled on 5 points. high acuity illness) 1-5 points
based on severity and risk of
complication.
Every case is reviewed and scored. Scores correlate
to priority order. Tie scorers go in FIFO order.
Figure A
The Care Plan Model
In order to provide input into each patient’s care plan, a
committee was assembled which represented multiple service lines
within the organization. The committee comprised an ED physician,
a general practitioner medical physician, the organization’s physician
advisor to care management, the vice president of medical affairs, a
social worker from UPMC Presbyterian’s behavioral health entity and
the organization’s director of collaborative care management. The
intent of the committee was to collectively develop a system to more
consistently manage complex or challenging patients. Through this
model, their goal was to ensure they sought the services they needed
from a clinical standpoint, remained in compliance with the
continued on page 10

9
 w w w . a c m a w e b . o r g
A Consistent Approach to Quality Care: Examining an Effective Care Plan Model for Complex Patients
(continued from page 9)
established clinical plan and followed their discharge from the ED or
hospital setting.
The organization’s physician advisor is the main driver of the
program. She develops individual care plans based on the input of
the committee, as well as input from ED staff, the patient’s PCP, and
for patients involved in the pain clinic, she works with their pain
physician. When developing care plans, the physician advisor also
works collaboratively with the organization’s internal acute care
physicians. All of these individuals are asked to review the care plan
and provide input, as well as any edits or additions as they pertain to
their expertise. Once all input and feedback has been gathered, the
care plan is reviewed and finalized by the committee.
The care plan model for complex patients at UPMC Presbyterian
is a physician-driven system, not only in terms of the collaboration
between physicians and other specialists at the committee level and
the leadership of the organization’s physician advisor in the
development of the care plan, but also in respect to the actual
execution of the plan. Once an individual plan has been developed
and approved, it is ultimately the responsibility of the patient’s
attending physician to ensure that the care plan is followed.
The care plan model for complex patients at UPMC Presbyterian
has been underway for one year. As the model develops and grows,
improvements have been made throughout the process to ensure
that the system provides adequate care for the patient and addresses
specific needs of the complex patient. The committee’s feedback is
influential in these improvements and updates, and the format of the
program has evolved and grown as a result. A recent update to the
system was the addition of disclaimers. This change resulted from
concerns that the care plan may be perceived as dictating clinical
care to those who are asked to follow it. In order to address these
concerns, a succinct disclaimer was added to the care plans. The
disclaimer essentially indicates that the plan is a guideline and is in
no way meant to impede the physician’s judgment or care of his or
her patient.
Though variables of the program’s format have been updated and
improved throughout the system’s brief tenure, to date the criteria for
identifying complex patients and the stratification techniques
employed to prioritize patient care plans have remained unchanged.
Key Considerations
When developing care plans for complex or challenging patients,
it is critical to have a continuous dialogue with the patient’s PCP and
the ED physician(s) who interact most with the patient. One can
comb through charts in an effort to isolate the patient’s issues and
trends, but until conversations occur between those who have
worked closely with the patient throughout his or her medical history,
10
it is often difficult to gauge the exact issues.
These conversations can often unearth important behaviors which
may otherwise go undetected. It is critical to note such patterns in the
patient’s care plan. For example, upon speaking with a particular
patient’s PCP, it became clear the main reason the patient returns to the
hospital was to satisfy her need for social interaction. This particular
patient enjoys coming to the ED because everyone smiles at her,
engages her and provides her with coloring books and crayons.
In this regard, it is important to determine what factors reinforce
the patient’s negative behaviors or patterns of readmission.
Identifying the impetus of the issue empowers the physician
responsible for the patient’s care to take corrective measures and
determine what practices or treatments need to be changed or
modified to discourage such patterns. Another example, one patient
repeatedly presents at UPMC Presbyterian with a fever. Upon further
investigation it was found that the patient had been falsifying her
temperatures. In order to address this behavior, the care team began
to take temperatures from the axilla, as it is more difficult to falsify
temperatures with this approach. This was subsequently noted in the
patient’s care plan.
Once a system for developing patient care plans is established, it
is vital to market the concept. It is impossible for care plans to be
effective if no one is aware of their existence. In this regard,
consistency and follow-up are also imperative. Measures must be
taken to ensure that physicians are informed of the care plan process
and that they adhere to it. Physicians who execute the care plan
should receive continuous follow-up from the rest of the care team to
ensure the care plan is followed, and if not, the reasons for non-
compliance must be addressed.
Challenges
Developing specific care plans is a significant time investment.
Large amounts of information and patient data must be compiled
into a single guide. Invariably, the plan must be sent and resent to
multiple parties until all edits and revisions have been submitted and
the plan is complete. Additionally, care plans are always subject to
change. In some instances the patient’s needs have changed by the
time the plan is finalized. The time investment can be challenging for
practitioners with many competing obligations. However, the
initiative is worth the investment in terms of improved care and
overall quality.
Perhaps the greatest challenge to the process is compliance. Just
because the plan is in place does not guarantee that those tasked with
following it will in fact do so. A consistent approach and a standard
system for follow-up ensures compliance and encourages
practitioners to buy-in to the program.
continued on page 11
 C O L L A B O R A T I V E C A SE M A N A G E M EN T

A Consistent Approach to Quality Care: Examining an Effective Care Plan Model for Complex Patients
(continued from page 10)

Outcomes
As the care plan model for complex patients is relatively new, many
of the initiative’s quantifiable outcomes have yet to materialize. However,
a number of the program’s benefits have become immediately apparent.
The care plan model undoubtedly reduced the amount of resources
and time spent caring for complex patients. By following an established
plan of care that notes behavioral patterns or specific considerations, the
organization’s care team has been able to effectively care for patients
who previously represented a challenging course of treatment. The care
plans truly allow one physician to pick up with the same patient where
another may have left off.
Though the results have yet to be measured, it is estimated that the
implementation of care plans will lead to a decrease in the organization’s
average length of stay (LOS). Following a detailed care plan allows the
practitioner to focus on the actual issue without the added unnecessary
components and “guess work” that formerly accompanied many
complex patients. In doing so, the potential exists to greatly minimize
the stay component.
Another positive outcome of the system is buy-in from the ED. The
care plan makes the processes within the ED much easier, and as a
result, ED physicians have been very supportive of the care plans. UPMC
Presbyterian’s physician advisor recently met with an ED physician who
provided her with 20 care plans. Such support and willingness to provide
input into the ED component of the care plans greatly expedites the
process and fosters positive working relationships between departments.
Perhaps the effectiveness of the program to date is best displayed in
a case example. When those involved in the care of a particular patient
began to set consistent processes for his clinical care as well as his
behavior and compliance, they began to observe a drastic increase in his
number of ED visits. Discouraged by the consistency of care he
experienced as a result of his care plan, the patient would present at
many EDs within the UPMC health system in an attempt to find a
variance in his care. In some cases, the patient would even present at the
same facility at multiple times on the same day. Shortly after the increase
occurred, a dramatic decrease in the patient’s inpatient admissions was
observed when compared to his admissions prior to the care plan’s
implementation (see Figure B). This improvement is a direct result of the
patient’s standard plan of care. Such successes serve as strong
motivation to adhere to guidelines in order to improve the overall
standard of care and create efficient work processes within the facility.
Neena Reddy, MD, is a Board-Certified Internal Medicine Physician,
and has been the Physician Advisor for Collaborative Care
Management at UPMC Presbyterian since 2007. She has served as a
hospitalist for 7 years, focusing on inpatient care, management and
discharge planning. She completed her Internal Medicine Residency in
2003 at UPMC Shadyside Hospital in Pittsburgh PA.
Ann Kostial, RN, BS, MHA, has been the Director of Collaborative Care
Management at UPMC Presbyterian/Shadyside since 2004. She earned
her nursing degree from Kent State University and her MHA from the
University of St. Francis. During her career she has been a surgical,
urology, orthopedic and pediatric ICU nurse. She has spent the last 20
years in managed care in both the insurance and hospital settings. She
has broad experience and knowledge in utilization review, discharge
planning and care management. She has been in a management
position within the managed care/hospital arena for the past 12 years.

RESULTS OF CARE PLAN

Encounter Activity Per Month • Care Plan - Patient DH • Confidential Peer Review Protected

10
4/09-Care Plan 7/09-Care Plan 12/09-Care Plan
9
Developed Formalized Enforced
8
7
# of Encounters

6
5
4
3
2
1
0
Sep 08 Oct 08 Nov 08 Dec 08 Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10
Emergency 1 5 2 3 1 1 5 3 1 3 4 3 4 9 1
Inpatient 1 1 3 2 1 2 2 1 2 1 2 1
Observation 1 1

Figure B

11