Date of Graduation

Winter 12-13-2019

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Executive Leader DNP

First Advisor

Dr. Mary Bittner

Second Advisor

Dr. Elena Capella


Improving disposition management of complex hospitalized patients is crucial to the success of acute care facilities. Most hospital patients discharge in less than 5 days, but there is a cohort of complex patients whose length of stay far-exceeds the norm (Centers for Medicare and Medicaid Service Website, n.d.). Today’s case managers are focused on patients who are discharging today or tomorrow in order to keep hospital census cycling through. This phenomenon known as “throughput” drives daily operations and is a measure of success. When case managers are faced with complex patients whose length of stay measured in weeks, months, or even years they are not equipped with knowledge and skills to execute on the interventions required. The focus of this project was the identification, development, and application of advanced case management competencies to address the disposition needs of the complex patient.

Incorporating the competency map developed by the Case Management Society of America (CMSA) and corresponding case manager self-assessment in conjunction with additional resources, the project was implemented in a large integrated healthcare system in Northern California. The pre-work was well underway as the system had identified over 100 hospitalized patients spread across 21 medical centers with length of stay greater than 30 days. A small percentage (3%) of this group had a length of stay greater than one year. An analysis determined the patients could be categorized in one of 6 sub-categories: 1. acute/complex 2. psychosocial & financial concerns 3. legal issues 4. long stay by protocol (i.e. cancer treatment) 5. end of life seeking full treatment and 6. stable/no bed available. A team was created to address the unique disposition needs of this patient population. From this work, an analysis determined key competencies for complex patient disposition were missing in the routine work of the organization’s case managers. A resource playbook was assembled as the basis for advanced competency education incorporating the Case Management Society of America (CMSA) standard competency self-assessment.

An educational intervention was developed for a pilot in two of the system’s acute care facilities. The intervention included deployment of a four-hour curriculum delivered through an interactive in-person learning environment collecting qualitative and quantitative data using formative and summative evaluations. A total of 63 nurse case managers attended the courses which were delivered in four 1-hour sessions. Of the nurses who participated in the pre and post- formative surveys, 92% (n=58) strongly agree they gained confidence in their skills managing complex patient discharges. The results of this evidence-based project demonstrate the importance of advanced competency education for complex patient dispositions. Additional outcomes demonstrate the value of a skilled case management workforce leading to successful patient transitions.