Trinity Health System's Complex Care Model

Multistate

Trinity Health has implemented a Complex Care model that was developed by Mercy Health in western Michigan, and is designed to target super-utilizers. Using a Complex Care Map embedded in a patient's electronic health record, providers can quickly review a one-page analysis of a patient's situation - including medical, behavioral and social issues - and read evidence-based recommendations for care. As of October 2016, the program has been rolled out to more than 86 hospitals in 21 states across the country and is being implemented as a standard of best practice for all EDs within Trinity Health. 

Partner Organizations

• Trinity Health System
• Mercy Health Saint Mary's

Target Population

Patients with complex needs 

Care Team

 Clinical nurse leader, RN, multidisciplinary virtual team

Timeframe

2012 - present

Results/ Studies

Cross-Continuum Tool Is Associated with Reduced Utilization and Cost for Frequent High-Need Users (The Western Journal of Emergency Medicine, 2016) 

Funding

Health system

Resources

Program description and results (2016 presentation)

Program description (2014 presentation)

Program description (American Academy of Nursing)

Complex Care Model Leads to Answers for America’s Vulnerable (Campaign for Action, 2017)