Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study

Abstract

Background Community hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance. Objectives (1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5). Methods Study 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of < 24 hours) and the National Audit of Intermediate Care. Results Community hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved (price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/ (accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions. Limitations The econometric analyses were based on cross-sectional data and were also limited by missing data. The low response rate to our national survey means that we cannot extrapolate reliably from our community hospital sample. Conclusions The results suggest that significant community hospital ward savings may be realised by improving modifiable performance factors that might be augmented further by economies of scale. Future work How less efficient hospitals might reduce costs and sustain quality requires further research. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Healthcare pathways and resource use: mapping consequences of ambulance assessment for direct care with alternative healthcare providers

“…However, alternatives to acute hospitals, such as care homes, special units, hospital-at-home services or community hospitals can, for certain older patients, be safe and possibly lower healthcare costs [ 30 ]. At the same time, neither cost effectiveness nor cost efficiency has been observed in studies comparing community hospitals to acute hospitals in care of older patients [ 31 , 32 ]. As there is a potential to improve outcomes and lower healthcare costs with alternative pathways, we recommend studies with comparable groups for older patients assessed with the decisions system in order to draw conclusions regarding costs and outcomes.…”

Characteristics and mortality rates among patients requiring intermediate care: a national cohort study using linked databases

“…Intermediate care units are an important part of the continuum of services for older people at points of deterioration in health, or when in transition between hospital, home or care home. The provision of palliative care is a commonly cited function of intermediate care units nationally [10] and internationally, but provision varies widely depending on service commissioning and if palliative care is formally recognised in the wider health system [11]. Sezgin et al's systematic review identified these settings as delivering key elements of an effective model of care for older people with multimorbidity [8].…”

“…Using validated comprehensive outcome measures in routine care is demonstrated to improve detection of unmet needs and individual priorities, provision of the right care at the right time and outcomes of care [41], for example, using the Integrated Palliative care Outcome Scale to assess person-centred comprehensive care needs in routine care [42]. [44].…”

“…skill mix) [18][19][20][21] (Additional file D: Table D2). The use of HSE data impeded wider exploration of associations with clinical variables or intravariations and heterogeneity between facilities that are common [8,10,11,44]. The cancer group formed a small proportion (4.8%) of the total cohort.…”

“…Patients and family carers describe these facilities positively placing particular value on location close to home that enables holistic and personalised care facilitated by multidisciplinary team working and support for difficult psychological transitions, for example, loss of independence with disease progression [10]. Systematic review evidence demonstrates that compared with acute hospital care, patients and family carers in intermediate care units report better experiences and care is cost-effective to support post-acute recovery and rehabilitation [8,11]. However, less considered is risk of end of life and the need for care orientated towards quality of life and comprehensive palliative care assessment.…”