Hospital to Home Transition for Patients With Stroke Under Bundled Payments.

Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.

Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure.

Background: Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks. Objective: To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care. Design: Decision analytic microsimulation model. Data Sources: Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data. Target Population: Patients with HF who were aged 75 years at hospital discharge. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Disease management clinics, nurse home visits (NHVs), and nurse case management. Outcome Measures: Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis: All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained. Results of Sensitivity Analysis: Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained. Limitation: Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings. Conclusion: In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF. Primary Funding Source: Swiss National Science Foundation, Research Council of Norway, and an Intermountain-Stanford collaboration.

Cost-effectiveness analysis of systematic fast-track transition from oncological treatment to specialised palliative care at home for patients and their caregivers: the DOMUS trial.

BACKGROUND: While hospitals remain the most common place of death in many western countries, specialised palliative care (SPC) at home is an alternative to improve the quality of life for patients with incurable cancer. We evaluated the cost-effectiveness of a systematic fast-track transition process from oncological treatment to SPC enriched with a psychological intervention at home for patients with incurable cancer and their caregivers. METHODS: A full economic evaluation with a time horizon of six months was performed from a societal perspective within a randomised controlled trial, the DOMUS trial ( Clinicaltrials.gov : NCT01885637). The primary outcome of the health economic analysis was a incremental cost-effectiveness ratio (ICER), which is obtained by comparing costs required per gain in Quality-Adjusted Life Years (QALY). The costs included primary and secondary healthcare costs, cost of intervention and informal care from caregivers. Public transfers were analysed in seperate analysis. QALYs were measured using EORTC QLQ-C30 for patients and SF-36 for caregivers. Bootstrap simulations were performed to obtain the ICER estimate. RESULTS: In total, 321 patients (162 in intervention group, 159 in control group) and 235 caregivers (126 in intervention group, 109 in control group) completed the study. The intervention resulted in significantly higher QALYs for patients when compared to usual care (p-value = 0.026), while being more expensive as well. In the 6 months observation period, the average incremental cost of intervention compared to usual care was €2015 per patient (p value < 0.000). The mean incremental gain was 0.01678 QALY (p-value = 0.026). Thereby, the ICER was €118,292/QALY when adjusting for baseline costs and quality of life. For the caregivers, we found no significant differences in QALYs between the intervention and control group (p-value = 0.630). At a willingness to pay of €80,000 per QALY, the probability that the intervention is cost-effective lies at 15% in the base case scenario. CONCLUSION: This model of fast-track SPC enriched with a psychological intervention yields better QALYs than usual care with a large increase in costs. TRIAL REGISTRATION: The trial was prospectively registered 25.6.2013. Clinicaltrials.gov Identifier: NCT01885637 .

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

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.

Factors associated with post-acute discharge location after hospital stay: a cross-sectional study from a Swiss hospital.

BACKGROUND: In 2012, Switzerland introduced the diagnosis-related group hospital payment system. Fearing that vulnerable patients may be discharged early, Acute and Transitional Care (ATC) was introduced to address the nursing care of patients who no longer needed an acute hospital stay. ATC is more costly for patients when compared to other discharge options like rehabilitation while providing less rehabilitative services. This study investigates factors associated with the place of discharge for patients in need of care. METHODS: Data was collected from 660 medical records of inpatients 50 years and older of the municipal hospital Triemli in Zurich, Switzerland. We used stepwise logistic regression to identify factors associated with their discharge into ATC or rehabilitation. RESULTS: Older patients with higher Delirium Observation Scale (DOS), lack of supplementary health insurance, resuscitation order and a lower social network were more likely to be discharged into ATC than rehabilitation. CONCLUSIONS: The association of supplementary health insurance and social network with discharge into ATC or rehabilitation is problematic because patients that are already vulnerable from a financial and social perspective are potentially discharged into a more costly and less rehabilitative post-acute care facility.

Implementation of a billable transitional care model for stroke patients: the COMPASS study.

BACKGROUND: The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework. METHODS: We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models. RESULTS: Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC. Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals. IMPLEMENTATION: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days. Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42-6.27, p = 0.002). Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC. CONCLUSIONS: COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.

Policy Flight Simulators: Accelerating Decisions to Adopt Evidence-Based Health Interventions.

EXECUTIVE SUMMARY: In this study, the authors used simulation to explore factors that might influence hospitals' decisions to adopt evidence-based interventions. Specifically, they developed a simulation model to examine the extent to which hospitals would benefit economically from the transitional care model (TCM). The TCM is designed to transition high-risk older adults from hospitals back to communities using interventions focused on preventing readmissions.The authors used qualitative methods to identify and validate simulation facets. Four simulation experiments explored the economic impact of the TCM on more than 3,000 U.S. hospitals: (1) magnitude of readmission penalty, (2) application to specific diagnosis-related groups, (3) level of cost sharing between payer and provider, and (4) capitated versus fee-for-service payments. The simulator projected hospital-specific economic effects. The authors used Monte Carlo methods for the simulations, which were parameterized with public data sets from the Centers for Medicare & Medicaid Services (CMS) and TCM data from randomized controlled trials and comparative effectiveness studies.Under current conditions, the simulation indicated that only 10 of more than 3,000 Medicare-certified hospitals would benefit financially from the TCM. If current readmission penalties were doubled, the number of hospitals projected to benefit would increase to 300. Targeting selected diagnosis cohorts would also increase the number of hospitals to 300. If payers reimbursed providers for 100% of the TCM costs, 2,000 hospitals would benefit financially. Under a capitated payment model, 1,500 hospitals would benefit from the TCM.Current CMS penalties-or reasonable increases-have little economic effect on the TCM. In the current environment, two strategies are likely to facilitate adoption: (1) persuading payers to reimburse TCM costs and (2) focusing on hospitals with higher bed occupancies and higher revenue patients.

Transition Home Plus Program Reduces Medicaid Spending and Health Care Use for High-Risk Infants Admitted to the Neonatal Intensive Care Unit for 5 or More Days.

OBJECTIVE: To evaluate the effects of a transition home intervention on total Medicaid spending, emergency department visits, and unplanned readmissions for preterm infants born at ≤366/7 weeks gestation and high-risk full-term infants. STUDY DESIGN: The Transition Home Plus (THP) program incorporated enhanced support services before and after discharge from the neonatal intensive care unit (NICU) provided by social workers and family resource specialists (trained peers) working with the medical team from October 2012 to October 2014. Rhode Island Medicaid claims data were used to study the 321 infants cared for in the NICU for ≥5 days, who were enrolled in the THP program. THP infants were compared with a historical comparison group of 365 high-risk infants born and admitted to the same NICU in 2011 before the full launch of the THP program. Intervention and comparison group outcomes were compared in the eight 3-month quarters after the infant's birth. Propensity score weights were applied in regression models to balance demographic characteristics between groups. RESULTS: Infants in the intervention group had significantly lower total Medicaid spending, fewer emergency department visits, and fewer readmissions than the comparison group. Medicaid spending savings for the intervention group were $4591 per infant per quarter in our study period. CONCLUSIONS: Transition home support services for high-risk infants provided both in the NICU and for 90 days after discharge by social workers and family resource specialists working with the medical team can reduce Medicaid spending and health care use.

A trial based economic evaluation of occupational therapy discharge planning for older adults: the HOME randomized trial.

OBJECTIVE: To compare the cost effectiveness of two occupational therapy-led discharge planning interventions from the HOME trial. DESIGN: An economic evaluation was conducted within the superiority randomized HOME trial to assess the difference in costs and health-related outcomes associated with the enhanced program and the in-hospital consultation. Total costs of health and community service utilization were used to calculate incremental cost-effectiveness ratios, activities of daily living and quality-adjusted life years. SETTING: Medical and acute care wards of Australian hospitals ( n=5). SUBJECTS: A total of 400 people ≥ 70 years of age. INTERVENTIONS: Participants were randomized to either (1) an enhanced program (HOME), involving pre/post discharge visits and two follow-up phone calls, or (2) an in-hospital consultation using the home and community environment assessment and the Lawton Instrumental Activities of Daily Living assessment. MAIN MEASURES: Nottingham Extended Activities of Daily Living (global measure of activities of daily living) and SF-12V2, transformed into SF-6D (quality-adjusted life year) measured at baseline and three months post discharge. RESULTS: The cost of the enhanced program was higher than that of the in-hospital consultation. However, a higher proportion of patients showed improvement in activities of daily living in the enhanced program with an incremental cost-effectiveness ratio of $61,906.00 per person with clinically meaningful improvement. CONCLUSION: Health services would not save money by implementing the enhanced program as a routine intervention in medical and acute care wards. Future research should incorporate longer time horizons and consider which patient groups would benefit from home visits.

SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients' Healthcare from Skilled Nursing Facilities to the Community.

We assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This work was sponsored through a grant from the Association of Subspecialty Physicians (ASP). Members of the team mapped the process of discharging patients from a skilled nursing facility into the community and subsequent care of their outpatient PCP. Four areas of process improvement were identified, building on the prior work of the AMDA Transitions of Care Committee and the experiences of the team members. The team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish. The goal of these consensus-based recommended best practices is to provide a safe and high-quality transition for patients moving between the care of their SNF physician and PCP.

The Alice Springs Hospital Readmission Prevention Project (ASHRAPP): a randomised control trial.

BACKGROUND: Hospitals are frequently faced with high levels of emergency department presentations and demand for inpatient care. An important contributing factor is the subset of patients with complex chronic diseases who have frequent and preventable exacerbations of their chronic diseases. Evidence suggests that some of these hospital readmissions can be prevented with appropriate transitional care. Whilst there is a growing body of evidence for transitional care processes in urban, non-indigenous settings, there is a paucity of information regarding rural and remote settings and, specifically, the indigenous context. METHODS: This randomised control trial compares a tailored, multidimensional transitional care package to usual care. The objective is to evaluate the efficacy of the transitional care package for Indigenous and non-Indigenous Australian patients with chronic diseases at risk of recurrent readmission with the aim of reducing readmission rates and improving transition to primary care in a remote setting. Patients will be recruited from medical and surgical admissions to Alice Springs Hospital and will be followed for 12 months. The primary outcome measure will be number of admissions to hospital with secondary outcomes including number of emergency department presentations, number of ICU admissions, days alive and out of hospital, time to primary care review post discharge and cost-effectiveness. DISCUSSION: Successful transition from hospital to home is important for patients with complex chronic diseases. Evidence suggests that a coordinated transitional care plan can result in a reduction in length of hospital stay and readmission rates for adults with complex medical needs. This will be the first study to evaluate a tailored multidimensional transitional care intervention to prevent readmission in Indigenous and non-Indigenous Australian residents of remote Australia who are frequently admitted to hospital. If demonstrated to be effective it will have implications for the care and management of Indigenous Australians throughout regional and remote Australia and in other remote, culturally and linguistically diverse populations and settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12615000808549 - Retrospectively registered on 4/8/15.

Those Left Behind From Voluntary Medical Home Reforms in Ontario, Canada.

PURPOSE: Health systems are transitioning patients to medical homes to improve health outcomes and reduce cost. We sought to understand the characteristics and quality of care for patients who did and did not participate in the voluntary transition to medical homes. METHODS: We used administrative data for diabetes monitoring and cancer screening to compare services received by patients attached to a medical home (n = 10,785,687) with services received by those seeing a fee-for-service physician (n = 1,321,800) in Ontario, Canada, on March 31, 2011. We used Poisson regression to examine associations in 2011 after adjustment for patient factors and also assessed changes in outcomes between 2001 and 2011. RESULTS: Patients attached to a fee-for-service physician were more likely to be immigrants and live in a low-income neighborhood and urban area. They were less likely to receive recommended testing for diabetes (25% vs 34%; adjusted relative risk [RR] = 0.74; 95% CI, 0.73-0.75) and less likely to receive screening for cervical (52% vs 66%; adjusted RR = 0.79; 95% CI, 0.79-0.79), breast (58% vs 73%; adjusted RR = 0.80; 95% CI, 0.80-0.81), and colorectal cancer (44% vs 62%; adjusted RR = 0.72; 95% CI, 0.71-0.72) compared with patients attached to a medical home physician in 2011. These differences in quality of care preceded medical home reforms. CONCLUSION: Patients left behind from medical home reforms are more likely to be poor, urban, and new immigrants and receive lower quality care. Strategies are needed to reach out to these patients and their physicians to reduce gaps in care.

The increase in healthcare costs associated with frailty in older people discharged to a post-acute transition care program.

BACKGROUND: older people are high users of healthcare resources. The frailty index can predict negative health outcomes; however, the amount of extra resources required has not been quantified. OBJECTIVE: to quantify the impact of frailty on healthcare expenditure and resource utilisation in a patient cohort who entered a community-based post-acute program and compare this to a cohort entering residential care. METHODS: the interRAI home care assessment was used to construct a frailty index in three frailty levels. Costs and resource use were collected alongside a prospective observational cohort study of patients. A generalized linear model was constructed to estimate the additional cost of frailty and the cost of alternative residential care for those with high frailty. RESULTS: participants (n = 272) had an average age of 79, frailty levels were low in 20%, intermediate in 50% and high in 30% of the cohort. Having an intermediate or high level of frailty increased the likelihood of re-hospitalisation and was associated with 22 and 43% higher healthcare costs over 6 months compared with low frailty. It was less costly to remain living at home than enter residential care unless >62% of subsequent hospitalisations in 6 months could be prevented. CONCLUSIONS: the frailty index can potentially be used as a tool to estimate the increase in healthcare resources required for different levels of frailty. This information may be useful for quantifying the amount to invest in programs to reduce frailty in the community.

Cost Analysis of an Advanced Practice Registered Nurse Transitional Care Model for Cardiac Patients.

Interest in care transitions has intensified in light of emphasis placed on hospital readmissions. This study provides a comparative analysis of the costs of providing transitional care through a program for cardiac patients against hospital readmission costs. The advanced practice registered nurse-managed BRIDGE model reduced health care costs associated with readmissions that were in excess of program costs. On average, there was a per-patient savings of $4,944 in avoided readmissions within 30 days of hospital discharge. Over the duration of the program, this equates to a $306,537 savings in patients with acute coronary syndrome. Nurse practitioners have a unique, holistic, and supportive approach to providing care that may make them ideal for the transitional care setting.

Healthcare resource use in patients of the Australian Transition Care Program.

OBJECTIVE: The aim of the present study was to describe, from the perspective of the healthcare funder, the cost components of the Australian Transition Care Program (TCP) and the healthcare resource use and costs for a group of transition care clients over a 6-month period following admission to the program. METHODS: A prospective cohort observational study of 351 consenting patients entering community-based transition care at six sites in two states in Australia from November 2009 to September 2010 was performed. Patients were followed up 6 months after admission to the TCP to ascertain current living status and hospital re-admissions over the follow-up period. Cost data were collected by transition care teams and from administrative data (hospital and Medicare records). RESULTS: The TCP provides a range of services with most costs attributed to provision of personal care support, case management, physiotherapy and occupational therapy. Most healthcare costs up to 6 months after transition care admission were incurred from the hospital admission leading to transition care and from re-admissions. Orthopaedic conditions incurred the highest costs, with many of these for elective procedures and others resulting from falls. Hospital re-admission rates in the present study were 10% lower than in a previous evaluation ofthe TCP. Over 6 months, approximately 40% of patients in the study were re-admitted to hospital at an average cost of A$7038. CONCLUSIONS: Although the cost of the TCP is relatively high, it may have some impact on reducing hospital re-admissions and preventing or delaying residential care admissions.

Assessing the need for a medical respite: perceptions of service providers and homeless persons.

For homeless persons, posthospitalization care is increasingly provided in formal medical respite programs, and their success is now reported in the literature. However, there is a dearth of literature on posthospitalization transitional care for homeless persons in the absence of a respite program. Through this formative study, we sought to understand the process of securing posthospitalization care in the absence of a formal homeless medical respite. Results demonstrated a de facto patchwork respite process that has emerged. We describe both human and monetary costs associated with patchwork respite and demonstrate opportunities for improvement in homeless health care transitions.

The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial.

OBJECTIVE: To evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care. METHODS: The intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression. RESULTS: No significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained. CONCLUSION: The CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care.