Development of an Ambulatory Care Complex Patient Management Process

The dismissal of patients from care in ambulatory care practice locations often results from behavioral concerns that oftentimes escalate to incidences of workplace violence. In August 2023, the organization identified a larger-than-expected volume of patient dismissals and a lack of standardized workflows surrounding processes related to patient dismissal through a review of patient grievance information. A multidisciplinary team was formed, led by nursing and executive medical leadership and inclusive of quality, regulatory, risk, legal, and social work. This team examined related processes across other specialties to manage complex patients to understand best practices.
A robust policy and procedure was developed in addition to an associated educational toolkit. The toolkit contains an outline of best practices that includes a newly developed patient responsibilities document, examples of scripting for difficult conversations, a behavioral contract template, examples of appropriate documentation, and a list of internal organizational resources. The toolkit also contains a decision guide for clinicians with two pathways, referral to the complex case committee for consult and request to the patient dismissal committee for consideration of dismissal. Both the complex case committee and dismissal committee were newly launched as part of the work to provide oversight and a framework for a standardized approach. The goal of this work was to promote local autonomy in managing difficult patient situations to improve patient outcomes through decreasing patient dismissals, decrease the legal and regulatory risks to the organization by ensuring thorough documentation as well as enhancing patient's likelihood to maintain a therapeutic relationship with the care team, and decrease incidences of workplace violence during in person, virtual, and telephonic encounters. Patient dismissals are tracked via an electronic health record report and incidences of workplace violence are tracked in the organization's event reporting system.
Since go-live, there has been a significant decrease in the number of patient dismissals from a high of 205 or 0.168% of total patients arrived for encounters in May 2023 to 62 or 0.0509% of total patients arrived in May 2024. Instances of workplace violence, threats, and incivility continue to be tracked in the organization's event reporting system and have demonstrated a decrease from 0.00794% in August 2023 to 0.00351% in April 2024.
Learners will gain insight into how the organization approached the management of complex patients in ambulatory care practices and how transparency, standardization, and education led to a significant decrease in patient dismissals as well as decrease in workplace violence.