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 hospitalbased 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

High‐need high‐cost patients: A Concept Analysis

“…Similar research exists demonstrating that interventions focused on integrating health and behavioral resources (reducing fragmentation) can improve medication and disease management, prevent acute exacerbations, and reduce preventable health service utilization 9,16,27,29,33 . These findings validate the existence of a feedback loop by demonstrating the relationship between fragmented care, acute health conditions, and preventable health service utilization.…”

“…This group is largely identified as adults over the age of 65 who are insured by Medicare or are dually eligible for Medicaid 3,9,12 . The most frequent chronic conditions stated explicitly in the literature for HNHC patients include hypertension, coronary artery disease, congestive heart failure, diabetes, asthma, and chronic obstructive pulmonary disease 16,17 …”

“…Existing research implies the existence of a feedback loop by demonstrating how reducing fragmentation can impact health service utilization in HNHC patients 32 . One quasiexperimental study found that enhanced care coordination (i.e., discharge planning, follow‐up appointments, and education) led to a 39% reduction in ED visits, 25% reduction in hospitalizations, and a 79% reduction in 30‐day readmissions in HNHC patients 16 …”

“…While the vast majority (80%) of HNHC patients have insurance, 3 many report challenges accessing care after‐hours, receiving a same‐day answer to medical concerns, or obtaining timely care and information 1,15 . HNHC patients are more likely to be low income and subsequently cite cost‐related barriers to accessing care or managing their chronic conditions, such as difficulty affording medication 15,16 …”

“…In a negative feedback loop, patients have care that is well integrated between providers leading to decreased instances of acute exacerbations and preventable health service use 16,40,41 . Effective care integration is also associated with improved clinical outcomes, management of ongoing conditions, and reduced caregiver burnout 18,42 .…”