Need advice on criteria for case load

[ovnerati]

I am a new employee working for a health program that specializes in helping long term care clients return to their communites, either through assisted living, independant livings, or in their own homes. I am the programs first and only nurse to date. I was hired on with the specific purpose of managing a case load of medically complex clients. The program has never offered this service before and will only take patient's by referral. I have been asked to choose what criteria qualifies a patient as medically complex, and hence will be choosing what patients will be in my caseload.

The population I serve must qualify for nursing home level of care, so a great majority already have multiple medical complications. Does anyone have suggestions on what type of situations would qualify a patient with nursing home level of care to be "exceptionally" medically complex? Initially I intend to take any patients who are referred to the program, but I would like to provide some general examples to my providers as examples of what a patient they refer might look like?

Any suggestions on criteria or examples of an "exceptionally medically complex" nursing home patient would be appreciated.

[SummerGarden, BSN, MSN, RN]

If you want to start somewhere, ask your referring clients about the problem they need you to solve through the use of your services. In other words, if I were to use you, why? What can you do for me (a hospital CM) that I cannot do for my patients myself prior to discharge (BTW, I am sure that there is a lot you can do for me)?

[Dancer1nRed]

What is the purpose of transitioning clients from nursing home level to community?

Sounds like your job is more of a transitional model. Great transitional models are Eric Coleman's Care Transitions Intervention (CTI), and Mary Naylor's Transitional Care Model. Google them both and learn about them. They are mostly used from acute inpatient into community now, but I don't see why not use for nursing home to community; I think they'll be good references that'll give you ideas. They are based on a number of things: # of admissions in the hospital in a time frame, age factor, diagnoses, etc. I strongly encourage you to look them up.

And it might be different as to what population you serve. Are LTC residents in nursing home Medicaid population? Or elderly with medical complex issues. Or both? Some may be appropriate to be in nursing home, but not elsewhere because many became LTC because they failed in the community (be it assisted living, indep. living, etc.). So maybe you can look at whether the LTC residents have trialed transitioning into the community in the past and failed? Best wishes to you!