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American Association for Physician Leadership
American Association for Physician Leadership

Complex Care Center: A Tool for the Care Continuum Conundrum

by Venkat L. Prasad, MD, FAAFP, MBA/MHA, CPE | Kristine Fay, MHA, CMPE | Cie Mora, MSW, CMPE

June 8, 2020


The state of healthcare for patients navigating the care continuum is not ideal. Transitions of care are traps with unintended adverse outcomes that patients and overburdened staff have to navigate, especially vulnerable populations. Lack of continuity of care, preventable errors, and missed opportunities in closing care gaps can lead to poor outcomes, readmissions,2-5 increased costs, and worsening of morbidities. Consequently, patient experience tends to suffer.

One of the finest definitions of complex care is provided by Humowiecki et al1: “Complex care is a person-centered approach to address the needs of people who experience combinations of medical, behavioral health, and social challenges that result in extreme patterns of healthcare utilization and costs.”

The state of healthcare for patients navigating the care continuum is not ideal. Transitions of care are traps with unintended adverse outcomes that patients and overburdened staff have to navigate, especially vulnerable populations. Lack of continuity of care, preventable errors, and missed opportunities in closing care gaps can lead to poor outcomes, readmissions,2-5 increased costs, and worsening of morbidities. Consequently, patient experience tends to suffer.

Missteps in communication,6 medication reconciliation errors, pending test results, inadequate discharge instructions,7 and delays in follow-up can all add a heavy burden to an already fragile patient. An aging population, the increasing complexity of patients’ medical needs, rising case mix indices, and patients who are sicker at admission all compound the problem.

Transformative healthcare redesign and delivery adds additional pressure on healthcare systems to meet the Quadruple Aim of high quality, low cost, patient experience, and physician and staff satisfaction.

Porter and Lee8 advise providers to lead the transition from a supply-driven, physician-centric system toward patient-centeredness with an integrated practice unit (IPU), where a dedicated ultidisciplinary team, made up of both clinical and nonclinical personnel, provides care across the continuum. Systems where IPUs exist show similar results—timely treatment, improved outcomes, cost savings, and growth in market share.

A complex care center provides a hospitalist physician–led multidisciplinary team made up of nurses, care coordinators, pharmacists, dieticians, social workers, infusion teams, and wound care specialists, among others, to help improve outcomes and lower costs. It can play a key role in driving the value proposition under various alternative payment models.

A complex care center or an expanded post-discharge clinic or transitions clinic occupies the space between the patient’s home and other access points for care delivery. Such a facility can help mitigate some of the problems associated with care transitions and can function as an IPU such as those advocated by Porter and Lee.8 The complex care center can take on outpatient management for conditions such as urinary tract infections, foot problems related to diabetes, deep vein thrombosis, and congestive heart failure. It also can address social determinants of health that can drive utilization and costs, and decrease length of stay in an acute facility, by appropriate and timely follow-up.

Our Solution

The catalyst for our complex care center was starting a Next Generation Accountable Care Organization, the Best Care Collaborative, at Lee Health in Fort Myers, Florida. We needed to increase the value paradigm (high quality at low cost) for our attributed patients. This involved the following:

  • Bringing a sharper focus to readmissions;

  • Providing better access for patients without a primary care physician and those who could not get to their doctors in a timely manner; and

  • Providing additive services of wound care, IV infusions, and close monitoring or follow-up that would enable us to decrease emergency department use, especially for ambulatory care-sensitive conditions and also decrease lengths of stay in the hospital.

Our clinic design, based on Humowiecki’s1 definition of complex care, was a true complex care center, different from a transitional care clinic or post-discharge clinic, in addressing all the medical, behavioral, and social challenges that negatively impact patients during transitions of care.

We also considered innovations such as telehealth and remote monitoring to enable improved care coordination, medication reconciliation, counseling, and monitoring.

Our solution was to use hospitalists to staff and support the complex care center, given their versatility and scope of practice. By not replicating a traditional primary care office and not providing chronic disease follow-up care, we countered any “loss of my patient” concerns from primary care physician offices.

The operational plan involved three phases (Figure 1). The case vignettes that follow highlight some of these successes.

Figure 1. Components of the three-phase implementation plan. ACO, Accountable Care Organization; SNF, skilled nursing facility.

Case Vignettes


Following his hospital discharge, John went “home” to a homeless shelter. He had difficulty with his medications, no insurance, severe congestive heart failure (CHF), and no primary care physician. He presented to the complex care center with acute CHF despite his recent hospitalization. He received IV diuresis daily for three days with laboratory checks. A social worker obtained a walker and coordinated taxi transportation for his appointments, and the pharmacist helped simplify the treatment regimen and reconcile multiple medication changes resulting from his hospitalization. After three days of aggressive outpatient management he was stabilized, and readmission was avoided.


Dwayne had major depression, a history of suicidal ideation, and several chronic medical issues for which he was being followed in the complex care center. Over the course of his visits, he developed a trusting relationship with the social worker. She had helped him with clothes and shoes from the homeless pantry (donated items from staff) and coordinated transportation from the homeless shelter as needed. One day Dwayne called the front desk in tears, distraught, with suicidal thoughts following an allegation of theft at the shelter. The social worker, physician, and office manager engaged him on the phone while simultaneously working with law enforcement to locate him and bring him to the center. The team coordinated a transfer to another homeless shelter and coordinated care with a psychiatrist and behavioral health team.


Eddie, a Haitian patient, was referred to the complex care center following an admission for newly diagnosed diabetes mellitus. He spoke no English. He had no established primary care doctor, no insurance, and no money to pay for his care. His wife, who spoke English, accompanied him to his visits. At intake, his blood sugar was over 300 and he admitted to not taking his insulin because he was working two jobs and ate irregularly. Furthermore, he held cultural beliefs that required his wife to give him the injections, but she was away at work when he was home. With only one car between them to get to their three jobs, they were not able to attend the diabetes education sessions offered in Haitian Creole. Extensive coordination among nurses, physicians, social services, pharmacy, and community outreach was orchestrated. After numerous visits, this man’s blood sugar is finally under control.


Steve, an IV drug user, came to the complex care center after an against-medical-advice discharge from the hospital. He had fever, chills, hypotension, and leukocytosis (clinically septic) in the setting of active IV drug use. Blood cultures were positive. He was still symptomatic when he came to the center and refused admission. The care team was forced to treat him in the outpatient setting. He came daily for IV antibiotics. An echocardiogram and chest CT also were done as an outpatient. After two weeks of antibiotics, the patient’s symptoms resolved, and Steve was followed by an addiction medicine specialist, his cardiologist, and a primary care doctor.


From August of 2018 to July 2019 our complex care center had 27,864 visits. The top ten diagnoses were abscesses, complicated urinary tract infections, cellulitis, hypertension, sepsis, chest pain, abdominal pain, chronic obstructive pulmonary disease, diverticulitis, and motor vehicle accidents.

Ideal space requirements for a comprehensive complex care center would be 9000 square feet. The current infusion center has managed to provide this pilot service in 4000 square feet.

The 30-day readmission rate for patients seen at the complex care center after hospitalization was 6.9%. Lee Health rates during the same time period were 15.6% to 17.2%.

Patient experience scores prior to opening the complex care center, based on seven months’ worth of data from the old complex care/infusion center, were, on average, 68.5%. This rating improved to 78.4% in the 10 months at the new complex care center.

The break-even point following conversion of the infusion center to the complex care center came at 13 months, and the center currently reports a positive variance of about $1.12 million (Figure 2). This excludes the cost avoidance from readmissions, which comes to about $13 million (calculated as 2424 readmissions avoided at $5394 cost per readmit).

Figure 2. 2019 Financial Statement of Lee Health Complex (FYTD 2019 Actual). IP, inpatient; OP, outpatient.


Without a keen understanding of and focus on purpose and its scope, the complex care center can falter and sputter. To that end, our staff and leadership are drafting a mission, vision, and scope statement that will bring discipline to the program.

Chief among challenges are finding space, getting support from other campuses, building a cafeteria choice of desired services for campuses to select, finding a good return on investment from revenue generated and costs avoided, obtaining funding to build 9000 square feet of a new center, and forecasting the actual numbers and scale of such centers needed. Staff turnover due to change in roles, EMR work flows, registration processes, and telehealth adoption are some other hurdles.

Other areas that need attention include the following:

  • Trying to embed a perioperative surgical home;

  • Managing patients who need healthcare on release from prison;

  • Obtaining preoperative clearances; and

  • Resolving issues regarding the management or care of patients receiving renal dialysis.


Adding telehealth has been a bumpy process. From June of 2018 to February 2019 a total of 237 patients were seen via telehealth following hospital discharge. A scheduler, using discharge lists of patients, made the hospital rounds to identify those patients, educate them on telehealth, activate MyChart (EPIC), and schedule the actual telehealth visit after discharge. It cost about $2000 to procure a workstation and phone for the nurse practitioner, and $4000 to obtain a registration set-up with scanner, phone, printer, iPad, and laptop. Some of the challenges that have put this initiative on hold include the need for a full-time scheduler to round on patients, challenges with patients who don’t have access to a computer or smartphone, MYChart activation rates, an Advanced Registered Nurse Practitioner who was out on Family Medical Leave, and registration clerks who lack the skill sets required for telehealth.


Navigating the care continuum is fraught with gaps in current healthcare delivery due to fragmentation, poor communication, high costs, inefficiencies, and waste. This is especially tragic given the distressing moments at which patients most often encounter the health system.7,9,10

Medicare continues to draw focus to the total cost of care and patient-reported outcomes. The 2014 IMPACT (Improving Medicare Post Acute Care Act) require providers to report on the functional status of patients.11

Leaving an acute care facility further exposes 49% of patients to medical errors, with 60% having pending tests and 37% patients needing further testing or follow-up that they and their primary care physician remain unaware of.6,7,12 Moore et al.7 also postulate that not following through on a care plan constitutes an implementation error as defined by the Institute of Medicine (IOM). In their study of 366 patients leaving the hospital, the most common medications that caused problems were cardiovascular (36.4%), gastrointestinal (27.3%), and pulmonary (13.6%).7 Forster et al.12 further implicated poor communication among hospital-based services, physicians, and patients and their primary care doctors and providers as contributory factors in preventable and correctable errors. Barriers to communication or lack of communication in transitions of patients has been reported elsewhere.5,13,14

Coleman et al.15 found that only 50% of patients have a follow-up appointment 30 days after leaving the hospital. Transition of care or post-discharge clinics have proven to drastically help lower readmission rates—by double-digit percentage in some cases—by improving access points for the discharged patient.2,3

Shu et al.4 enrolled 313 admitted patients from December 2009 to May 2010 to improve post-discharge outcomes and reduce post-discharge adverse events, by utilizing disease-specific care plans, follow-up phone calls, hot line counseling, and referral to a hospitalist-run clinic. They noted significant reductions in readmission rates (22% versus 14%) and reductions in mortality rates (25% versus 15%) and concluded that an outpatient clinic run by hospitalists can play an important role in improving post-discharge outcomes.

It is no secret that readmissions add a considerable burden to health systems and payers.5 Strategies that have proven successful in marked reductions of readmit rates have been use of interdisciplinary teams,4,5,13,16 use of hospitalists,4 early post-discharge follow-up,3 effective management of the social determinants of health13,14,17-19 and care coordination,14,20,21 and a structured discharge planning process.5,14,17

Burke et al.,22 in a study of 5085 patients from 2005 to 2012, demonstrated a 2.4-day decrease in length of stay in the hospital among the 538 patients who were followed in a post-discharge clinic run by hospitalists. Hospitalists, however, may not necessarily see a place for themselves in the post-acute space and may be reluctant to commit to follow-up care once a patient is discharged.23,24

Pharmacists, students, and advanced practice providers can support and lower error rates, adverse events, and readmissions in managing patients across the care continuum.13,21,25-30

Social determinants of health play a key role in managing patients through the care continuum. Failure to address these issues results in a futile exercise when trying to achieve the Triple Aim and change healthcare utilization and total cost of care. The National Research Corporation reported on a case study at Ascension Via Christi,17 where reduction of readmissions resulted in a $1.6 million cost avoidance. They assisted over 500 patients in 2015 with the Community Cares program, by helping them recover, following hospitalization, in their homes and reducing readmissions and ED utilization by 93%. A major arm of the program was to educate and empower patients to manage their own health conditions. In the first nine months of the program, 19,000 patients were contacted, and 3,200 patients were marked for additional follow-up. Enrolled patients had a readmission rate of 5%. A similar tactic used with patients discharged from the emergency department in 2016 saw a 98% reduction in ED visits. Chadwick, Vice President at Via Christi, states: “The Transitional Clinic empowers patients to take control and manage their healthcare and condition. As a result, our patients get healthier, Via Christi’s readmissions rates have declined, and we have been able to reduce unnecessary utilization of the most expensive settings of healthcare.”17

Similarly, at Parkland Hospital19 in Dallas, Texas, resourcing community support and improving communication led to significant savings and improved outcomes. With 85% of their patients uninsured or on Medicaid, the hospital spent $871 million on uncompensated care in 2016. The high utilizers—or “frequent fliers”—were straining the hospital’s finances. A sophisticated software platform enabled the hospital to easily refer homeless people discharged from the ED to shelters and pantries and to let social workers at those places see what their clients are doing. A single care plan for the patient was mandated. With one care plan, the entire community, through technology-enabled platforms, facilitated patients’ needs and reduced service times for these vulnerable populations from six months to one month, with better outcomes.

Having served over 28,000 patients at our complex care center, we have found that it is a good strategy to combat access, readmissions, and ED utilization, and to address social determinants of health, length of stay, patient and staff engagement, cost optimization, and outcomes in healthcare.

Existing transition of care (TOC) or post-discharge clinics or infusion sites can be reconfigured and upgraded to accommodate multidisciplinary teams and staff. By providing timely access during transitions and support by a diverse staff, the complex care center is able to address the areas of medication errors and follow-up testing, closing the loop on pending test results to improve safe transition for the patient. Staffed by hospitalist physicians, it also can improve hand-offs and communication between inpatient and outpatient care teams.

Searching for best practices among several high-quality TOC intervention models, Burke et al.13 found that multimodal interventions with a multidisciplinary team significantly advanced improvements in transitional care. Their ideal transition includes:

  • Post-discharge follow-up within seven days;

  • Aggressive monitoring and management of symptoms on leaving the hospital;

  • Care coordination;

  • Use of palliative care and hospice;

  • Help from community resources;

  • Empowering patients through education;

  • Medication reconciliations to keep patients from harm;

  • Proper use of the EMR and data to optimize information flow, including discharge notes; and

  • A robust discharge planning process early in the admission process.

Although telehealth and scaling can be challenges, our strategies have been proven elsewhere by other teams in solving the TOC and care continuum conundrum. We have demonstrated the value of a complex care center to help an organization advance its value transformation.


In this article we have described the current challenges in dealing with vulnerable patients navigating the care continuum. Our complex care center effectively helped address the areas of readmission, access, addressing social determinants, and costs of care. By using an existing infusion clinic, we were able to augment the center with a multidisciplinary team led by hospitalists. Solutions shown to drive success include the following:

  • Use of standardized processes and protocols;

  • Use of pharmacists;

  • Staffing by hospitalists;

  • Follow-up by phone call or telehealth;

  • Empowerment and education of patients;

  • Providing relief for commonly encountered social difficulties such as transportation, clothing, follow-up, wound care, and IV infusions;

  • Behavioral health interventions; and

  • A multidisciplinary team.

Literature review supports the role of such a hospitalist-staffed clinic under several different terms (e.g., post-discharge clinic, transition of care clinic) to help with care coordination, readmission rates, costs of care, access and follow-up barriers, and length of stay in hospital beds. We also discussed logistical details on how to staff and plan for such a center and challenges in trying to scale such a practice.


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   2.    Chakravarthy V, Ryan MJ, Jaffer A, et al. Efficacy of a transition clinic on hospital readmissions. Am J Med. 2018;131:178-184.

   3.    Seggelke SA, Hawkins RM, Gibbs J, Rasouli N, Wang C, Draznin B. Transitional care clinic for uninsured and Medicaid covered patients with diabetes mellitus discharged from hospital: a pilot quality improvement study. Hosp Pract. 2015;42(1):46-51.

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10.   Baillie L, Gallini A, Corser R, Elworthy G, Scotcher A, Barrand A. Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study. Int J Integr Care. 2014;Jan-Mar;14:e009. DOI: 10.5334/ijic.1175.

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19.   The frequent flier program that grounded a hospital’s soaring costs. Accessed October 5, 2019.

20.   Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the costs of care for chronic disease. JAMA Intern Medicine. 2014;174:742-748.

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23.   Ryan PP, Stickrath C, Burke RE. Post discharge clinic attitudes and experiences of hospitalists. J Hosp Med 2013;8(suppl 1);10:578-581.

24.   Palabindala V, Abdul Salim S. Era of hospitalists. J Community Hosp Intern Med Perspect. 2018;8(1):16-20.

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26.   Kilcup M, Schultz D, Carlson J, Wilson B. Post discharge pharmacists medication reconciliation impact on readmission rates and financial savings J Am Pharm Assoc. 2013;53:78-84.

27. Glettler E, Leen MG. The advanced practice nurse as case manager. J Case Manag. 1996;5(3):121-126.

28.   Taylor P. Comprehensive nursing case management. An advanced practice model. Nurs Case Manag. 1999;4(1):2-10.

29.   Miranda AC, Cole JD, Ruble MJ, Serag-Bolos ES. Development of a student-led ambulatory medication reconciliation program at an academic institution. J Pharm Pract. 2018;31:342-346.

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Venkat L. Prasad, MD, FAAFP, MBA/MHA, CPE

Chief Medical Officer, Lee Physician Group

Kristine Fay, MHA, CMPE

Chief Administrative Officer, Lee Physician Group, Home Health & Physician Services

Cie Mora, MSW, CMPE

System Director Hospitalist Medicine & Continuum of Care Services, Lee Physician Group

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