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Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study.

ABSTRACT: BACKGROUND:Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies. OBJECTIVE:To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, outcomes, and costs. DESIGN:Quasi-experimental study. PATIENTS:Among 2235 high-need, high-cost Medicare and Medicaid patients identified during an index inpatient hospitalization in a non-profit health care system in a medically underserved area with complete administrative claims data, 285 participants were enrolled in the SafeMed care transition intervention, and 1950 served as concurrent controls. INTERVENTIONS:The SafeMed team conducted hospital-based real-time screening, patient engagement, enrollment, enhanced discharge care coordination, and intensive home visits and telephone follow-up for at least 45 days. MAIN MEASURES:Primary difference-in-differences analyses examined changes in quality (primary care visits, and medication adherence), outcomes (preventable emergency visits and hospitalizations, overall emergency visits, hospitalizations, 30-day readmissions, and hospital days), and medical expenditures. KEY RESULTS:Adjusted difference-in-differences analyses demonstrated that SafeMed participation was associated with 7% fewer hospitalizations (-?0.40; 95% confidence interval (CI), -?0.73 to -?0.06), 31% fewer 30-day readmissions (-?0.34; 95% CI, -?0.61 to -?0.07), and reduced medical expenditures ($-?8690; 95% CI, $-?14,441 to $-?2939) over 6 months. Improvements were limited to Medicaid patients, who experienced large, statistically significant decreases of 39% in emergency department visits, 25% in hospitalizations, and 79% in 30-day readmissions. Medication adherence was unchanged (+?2.6%; 95% CI, -?39.1% to 72.9%). CONCLUSIONS:Care transition models emphasizing strong interdisciplinary patient engagement and rapid primary care follow-up can enable health systems to improve quality and outcomes while reducing costs among high-need, high-cost Medicaid patients.

SUBMITTER: Bailey JE

PROVIDER: S-EPMC6712187 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature

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Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study.

Bailey James E JE Surbhi Satya S Wan Jim Y JY Munshi Kiraat D KD Waters Teresa M TM Binkley Bonnie L BL Ugwueke Michael O MO Graetz Ilana I

Journal of general internal medicine 20190703 9

<h4>Background</h4>Many health systems have implemented team-based programs to improve transitions from hospital to home for high-need, high-cost patients. While preliminary outcomes are promising, there is limited evidence regarding the most effective strategies.<h4>Objective</h4>To determine the effect of an intensive interdisciplinary transitional care program emphasizing medication adherence and rapid primary care follow-up for high-need, high-cost Medicaid and Medicare patients on quality, ...[more]

PMID: 31270786

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Project description:Background & aimsWe estimated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases, and identified characteristics of high-need, high-cost patients, in a nationally representative sample.MethodsUsing Nationwide Readmissions Database 2013, we identified patients with at least 1 hospitalization between January and June 2013, and a diagnosis of inflammatory bowel diseases (IBDs), chronic liver diseases (CLDs), functional gastrointestinal disorders (FGIDs), gastrointestinal hemorrhage, or pancreatic diseases, with 6 months or more of follow up. We calculated days spent in hospital/month and estimated costs of the entire cohort, and identified characteristics of high-need, high-cost patients (top decile of days spent in hospital/month).ResultsPatients with IBD (n = 47,402), CLDs (n = 376,810), FGIDs (n = 351,583), gastrointestinal hemorrhage (n = 190,881), or pancreatic diseases (n = 98,432), hospitalized at least once, spent a median of 6 to 7 days (interquartile range, 3-14 d) in the hospital each year (total for all diseases). Compared to patients in the lowest decile (median, 0.13-0.14 d/mo spent in the hospital), patients in the highest decile spent a median 3.7-4.1 days/month in hospital (total for all diseases), with hospitalization costs ranging from $7502/month to $8925/month and 1 hospitalization every 2 months. Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients. Based on multivariate logistic regression, high-need, high-cost patients were more likely to have Medicare/Medicaid insurance, lower income status, index hospitalization in a large rural hospital, high comorbidity burden, obesity, and infection-related hospitalization.ConclusionsIn a nationwide database analysis of patients with IBD, CLD, FGID, gastrointestinal hemorrhage, or pancreatic diseases hospitalized at least once, we found that a small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs. Population health management directed toward these patients would facilitate high-value care.

Project description:Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico.A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24-26, 27-29, and 30-33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24-26, 27-29, and 30-33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses.Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis. Please see later in the article for the Editors' Summary.

Project description:ObjectivesWe employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system.MethodsHealth services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n?=?17) across medical, access, social, and mental health domains, 4) survey providers (n?=?8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients.ResultsHNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n?=?101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project.ConclusionsPartnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system.Impact statementEmploying partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.

Dataset Information

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study.

Publications

Effect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental Study.

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