Date of Award


Document Type

Restricted Access Thesis

Degree Name

Master of Arts in Nursing (MAN)



First Advisor

Joyce P. Miller, DNP, RN

Second Advisor

Katherine Martin, Ph.D., APRN, CNP

Third Advisor

Max Barry-Ristow, MSN, RN


Acute care hospitals experience barriers to discharging patients with complex needs. These complex needs can be related to the psychosocial and/or medical needs of patients. A project to address the care of patients with complex needs at a level-one trauma safety net hospital was developed. A multidisciplinary care team approach is beneficial in providing care and progressing to a timely discharge. A multidisciplinary team, identified as the complex care review team, was created to support the care teams with developing a plan of care, discharge planning, and difficult decision-making for patients with complex needs. Margaret Newman’s Health as Expanded Consciousness theory provided the theoretical foundation for creating and implementing the framework for the model of care. The complex care team model has successfully shifted the care for patients with complex needs, and a tool for tracking trends was created. The tracking tool will provide easy reference to past cases, trends, and identify the frequency that the complex care team is requested. Plans are in place to expand the complex care team model to a sister hospital within the organization.


SC 11.MAN.2022.Hoehn.K