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The “Right People in the Room” Approach to Complex Patients in a Large System

** This session earns SW, RN, and CCM Ethics ** 
The highest complexity patients often face barriers in addition to medical care. They often get stuck. This session will review how the Cleveland Clinic Health System created a multidisciplinary escalation team to review patients whose transition planning was stuck, and how this team approach not only generated success for these patients, but also created best practices for future issues. This approach is undertaken to act in the public interest, the team approach ensures participants maintain objectivity. The session will focus on the necessity of having the right people in the room, meaning a team comprised of people able to identify options for moving the patient forward, and engage stakeholders in the plan of care. Further, the team must include members with the autonomy to select a course to move forward, as well as the discretion to execute decisions along the way.

  1. Describe the utility of multi-disciplinary escalation teams in planning and evaluating patient post-acute care transitions.
  2. Identify the members of a multi-disciplinary escalation team and their roles.
  3. Summarize the efforts and recommendations of multi-disciplinary escalation teams.