Comparative Effectiveness of a Complex Care Program for High-Cost/High-Need Patients: a Retrospective Cohort Study

Abstract

BACKGROUND: High-cost/high-need (HCHN) adults and the healthcare systems that provide their care may benefit from a new patient-centered model of care involving a dedicated physician and nurse team who coordinate both clinical and social services for a small patient panel. OBJECTIVE: Evaluate the impact of a Complex Care Program (CCP) on likelihood of patient survival and hospital admission in 180 days following empanelment to the CCP. DESIGN: Retrospective cohort study using a quasiexperimental design with CCP patients propensity score matched to a concurrent control group of eligible but unempaneled patients. SETTING: Kaiser Permanente Mid-Atlantic States (KPMAS) during 2017-2018. PARTICIPANTS: Nine hundred twenty-nine CCP patients empaneled January 2017-June 2018, 929 matched control patients for the same period. INTERVENTIONS: The KPMAS CCP is a new program consisting of 8 teams each staffed by a physician and nurse who coordinate care across a continuum of specialty care, tertiary care, and community services for a panel of 200 patients with advanced clinical disease and recent hospitalizations.MAIN OUTCOMES: Time to death and time to first hospital admission in the 180 days following empanelment or eligibility. RESULTS: Compared to matched control patients, CCP patients had prolonged time to death (hazard ratio [HR]: 0.577, 95% CI: 0.474, 0.704), and CCP decedents had longer survival (median days 69.5 vs. 53.0, p=0.03). CCP patients had similar time to hospital admission (HR: 1.081, 95% CI: 0.930, 1.258), with similar results when adjusting for competing risk of death (HR: 1.062, 95% CI: 0.914, 1.084). LIMITATIONS: Non-randomized intervention; single healthcare system; patient eligibility limited to specific conditions. CONCLUSION: The KPMAS CCP was associated with significantly reduced short-term mortality risk for eligible patients who volunteered to participate in this intervention.

Identifying High-Cost, High-Need Patients in a Network of Community Hospitals

“…High costs may, in part, be attributed to a lack of access to primary care, poor control of chronic disease, and the need for care coordination. 4 , 8 - 10 Further, neighborhoods with greater social needs exhibit higher spending on potentially preventable healthcare such as preventable emergency department visits, preventable hospitalizations, and unplanned 30-day hospital readmissions. Structural and economic barriers adversely influence the health and well-being of people living in under-resourced communities, leading to disproportionate rates of chronic disease, utilization of emergency healthcare services, and mortality.…”

Identifying complex patients using Adjusted Clinical Groups risk stratification tool

“…4 For this group of patients, it would seem that a multidisciplinary and personalized approach would be advantageous, but evidence for the effectiveness of this kind of approach is still ambiguous. 5 One of the reasons is the incorrect assignment of patients to this intense but effective individualistic approach, leading to a greater mismatch in care. Hence, the first step in providing those complex patients with the appropriate necessary care is a practical and efficient identification of the population who is most likely to benefit from the intervention.…”