What Is a Clinically Complex Patient?

A clinically complex patient is described as having co-morbidities of several medical conditions, often with a cardiopulmonary overlay that significantly compromises the patient’s ability to function. Most of these patients have primary diagnoses that require nursing intervention and often have the presence of exacerbation and/or remission. In addition, there are often other challenges, such as low activity tolerance, lack of participation and low motivation.

The most common conditions among medically complex patients include but are not limited to:

  • Respiratory conditions (pneumonia, COPD/chronic bronchitis, emphysema, asthma, atelectasis)
  • Cardiovascular conditions (CHF, hypertension)
  • Metabolic conditions (renal failure, diabetes)
  • Infection (sepsis, systemic inflammatory response syndrome)

Due to the medical conditions present, therapy will need to have strong documentation to justify the need for intervention and the patient’s ability to tolerate intervention, especially at higher intensities. Note: Patients who are clinically unstable (uncontrolled hypertension/hypotension, arrhythmia, angina, etc.) will need to have their conditions stabilized prior to rehabilitation intervention.

Evaluation Considerations

When completing an assessment for a clinically complex patient, be sure to capture information regarding the patient’s respiratory function, cardiovascular function, endurance, polypharmacy and ability to tolerate functional activity. Assess vitals and labs such as heart rate, respiration rate, blood pressure, O2 SATs, pain, mental status and any other labs or pharmacology, and measure vitals at rest and with activity (compare to norms for that age group). Use a Dyspnea Scale such as the Perceived Exertion Scale (modified Borg scale) to record the patient’s respiratory function with and without activity.

When reviewing lab work, remember that normal lab values in the elderly are compromised by the high prevalence of disease and by age-related physiologic and anatomic changes, and drugs may alter the results of lab tests. Use appropriate references to determine normal values for each patient.

Be sure to capture current level of function during activity in the documentation, including percentage of trials, cueing levels and any outcomes from formal assessments (six-minute walk test, 30-second chair stand, arm curl, two minutes step in place, RPE, seated step test, senior fitness test, functional reach, incentive spirometry, etc.). Also include measurements of the patient’s physiological response to the activity, such as oxygen saturation levels, pulse, respiration and perceived exertion.

Establishing Goals

Determine how all of the information collected can be captured in functional goals. Goals need to be measurable, functional and sustainable. Goals for this population need to address:

  • Improving the patient’s ability to perform activities of daily living
  • Decreasing symptoms identified in evaluation that impact function
  • Increasing endurance and strength
  • Improving the patient’s quality of life
  • Decreasing negative consequences of deconditioning
  • Returning the patient to prior level of function (or beyond)
  • Include the patient and family to determine functional goals for discharge
  • Implement small, incremental goals that will be updated frequently for this population (modification of the goals and treatment plan are skilled services).

Skilled Intervention Considerations

  • Depending on the diagnostic results of each patient, treatment approaches will vary and need to tie back to the established goals.
  • Provide treatment during normal daily routines to help conserve energy, especially at the beginning of intervention.
  • Monitor vitals before, during and after activity (know the contra-indications for exercise with this population).
  • Reduce patient anxiety by providing treatment in their room or less active areas.
  • Keep therapy sessions short, or split the treatments as vital signs and patient ability dictate.
  • Make treatment modifications as the patient’s clinical tolerance dictates. Document the modifications and fluctuations in treatment approaches.
  • Integrating rest and assessment into treatment is critical for medically complex patients and is part of the provided treatment session.
  • Assessment of a patient’s condition, changes in recovery time, functional activity tolerance and mentation, assessment of vitals, and addressing levels of pain are all skilled interventions and essential to patients’ recovery.

Skilled Interventions

  • Postural management for pain relief and/or respiratory ease
  • Positioning for adequate respiration at rest and with activity
  • Breathing techniques at rest and with functional activity (resistive breathing, diaphragmatic and pursed-lip breathing)
  • Train coordination of breathing while speaking and other activities
  • Training and education in energy conservation for activity and ADLs (task segmentation, pacing, work simplification)
  • Provide support surfaces for pressure relief in bed and wheelchairs
  • Train clinically appropriate transfers
  • Ensure adequate hydration
  • Train airway protection strategies
  • Train safe coughing techniques
  • ROM exercises for improved strength, flexibility and coordination and peak work capacity
  • Head and neck exercises
  • Aerobic conditioning training
  • Balance and gait training
  • Integration of modalities
  • Psychosocial adaptations
  • Community reintegration
  • Home environment assessments
  • Patient education
  • Repeat diagnostics to compare patient function (six-minute walk test, RPE, Dyspnea Scales, etc.)

Progress Reports

A progress report shows how the patient is responding to intervention and their progress toward the goals, and it justifies continued skilled intervention for the patient. Continuation of services with no or minimal progress in a progress report period must be supported in the documentation. The justification statement also addresses how progress on the treatment goals has helped to move the patient closer toward meeting those goals. Justification statements for continuation of therapy services need to be written at least weekly.

Remember: Describing how the medical history impacts current functional status helps determine the circumstances that led to the need for skilled intervention.

The need for skilled intervention must make sense, support medical necessity and tie back to the goals. It is important to ask what could happen if skilled rehabilitation services were not initiated, such as safety risks and possible further decline.

The skills and techniques that can be taught to this population will improve not only the quality of their functional abilities, but also their quality of life.