The Complex Discharge Team (CDT) at UK HealthCare was created in 2015 to provide specialized care to patients with complex socioeconomic backgrounds and discharge needs on one dedicated unit. This multidisciplinary team provides holistic, individualized care to a wide array of patients, some of whom are afflicted with medical illnesses that become chronic co-morbidities that cause a decline in functional status.

 

“To re-engage such a complex patient population, we’ve had to be innovative, creative, empathetic and inspiring,” said Dr. Padmaja Gaddam, CDT Medical Director. The CDT comprises special individuals who persevere despite the odds, compulsively look at the bright side, and root for an optimistic and positive outcome. This team includes a medical director, patient care manager, physician, advanced practice provider, social worker, recreation therapist and nursing staff.

 

Many patients have mental health conditions or are homeless. They often stay on the unit for many weeks or even beyond a year. The recreation therapist works collaboratively with the team and other non-profit and philanthropic organizations to assemble a variety of activities that bring joy to patients. These include rocking chairs to soothe and calm patients with cognitive impairment, a room equipped with art supplies and a chalkboard wall to inspire creativity, and the use of iPads to enhance patient education.

 

“These patients, some of whom have not had a single friend or family visit them, have been touched by the empathetic care and diligence shown by providers,” said Dr. Gaddam.

 

One patient was admitted to their unit after a three-month hospitalization. She arrived with extensive pressure injuries and multiple psycho-social needs and spent more than a year on the unit. During her stay, the team’s expertise and patient-centered approach not only healed her wounds but also assisted in reconnecting her with her estranged, out-of-state relatives. She was ultimately safely discharged to the care of her adoptive family.

 

In addition to excellent patient safety and health outcomes, including no hospital-acquired infections or falls with injuries for two consecutive years, and a significant reduction in pressure injuries, the unit has strong staff dedication. There has been little turnover despite the workforce challenges facing nursing today. The nurses maintain special skills and receive additional training in palliative care and end-of-life support multiple times a year.

 

The team’s compassionate care helps build rapport with their patients—even those with challenging behaviors—as was the case with one young man. He was homeless and had multiple ICU stays due to complications of his unmanaged Type 1 diabetes and end-stage renal disease. He was initially uncooperative with care and hostile with staff. But the team’s resolute devotion made a difference, and over time he became more interactive and accepting of staff. He thanked every team member daily for the last two weeks of his life. His passing was dignified with a tearful eulogy, attended by every single team member.

 

“Compassion is being able to understand what other people are going through and feeling their pain, being mindful of their emotions, thoughts, and experience, and taking action when you see someone is suffering,” said Jamie Cross, Patient Care Manager.

 

“The Complex Discharge Team exemplifies in spirit and deed the essence of knowledge, care, compassion and empathy that help heal physical ailments and rejuvenate mind, body and soul,” said Dr. Gaddam.