At one urban academic health system, an acute care intervention bundle to improve transition planning after discharge was associated with large reductions in total cost of care, especially among Medicaid patients, and with mixed results for hospital utilization, a nonrandomized quality improvement study found.
As part of the study, which spanned from 2012 through 2016, researchers analyzed the effect of the bundle on hospital utilization, practitioner follow-up visits, and total cost of care for Medicare and Medicaid patients. The acute care intervention, which was part of the Johns Hopkins Community Health Partnership (J-CHiP) program, included six evidence-based services: 1) early screening for discharge planning, 2) daily multidisciplinary unit-based rounds, 3) patient education, 4) enhanced medication management, 5) postdischarge follow-up by phone, and 6) skilled home care, remote monitoring, and/or a skilled nurse transition guide for high-risk patients. Most of these services were set up across 35 adult inpatient units at two Johns Hopkins hospitals.
Researchers compared outcomes of intervention participants in the 90 days after their acute episode with those of a propensity score-weighted preintervention group at J-CHiP hospitals and a concurrent comparison group drawn from similar Maryland hospitals. Results were published online on Nov. 2 by JAMA Network Open.
The intervention group had 26,144 beneficiary episodes for Medicare patients (mean age, 68.4 years; 52.5% female). For Medicare patients, the intervention was associated with a $29.2 million reduction in aggregate total cost of care, largely driven by relative reductions in skilled nursing facility expenses. It was associated with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1,000 beneficiary episodes, respectively. The intervention was associated with a reduction in practitioner follow-up visits of 41 and 29 per 1,000 beneficiary episodes for seven-day and 30-day visits, respectively.
Among 13,921 beneficiary episodes for Medicaid patients (mean age, 52.2 years; 53.1% female), the reduction in aggregate total cost of care was $59.8 million, and practitioner follow-up visits decreased by 70 and 182 per 1,000 episodes for seven-day and 30-day visits, respectively. While the 90-day ED visit rate decreased by 133 per 1,000 episodes among Medicaid patients, hospitalizations increased by 49 per 1,000 episodes.
The study authors noted limitations, such as a lack of data from non-CMS payers and the fact that Maryland hospitals in the study started participating in health care delivery reforms in 2014. They added that the study did not include the cost of the intervention itself or a formal cost-benefit analysis.
Since the intervention used a bundle of services, it is unclear which components were most responsible for the cost reductions, which is an important consideration in resource-poor settings, an accompanying editorial noted. “It is also not clear how the costs (or savings) of care management interventions are spread across a health system or over a patient's entire continuum of care—that is, to what extent costs are not saved, but simply shifted,” the editorialists wrote.
Compared to other analyses of care management that have found more modest savings, the study suggests that comprehensive inpatient care coordination can be effective, “even, and perhaps especially, in socioeconomically disadvantaged areas like East Baltimore, Maryland,” they added.