Can Care Coordination Improve Outcomes?

Background

Healthcare in the US is the most expensive in the world and inpatient acute care represents the largest share of those costs. Attempts to reign in these costs have taken many forms, but a common approach has been policies designed to improve care coordination. Care coordination policies have ranged in scope from health systems (e.g. accountable care organizations) to the relationship between care team members. This study focuses on the latter end of the spectrum, estimating the effectiveness of a care coordination model for inpatient acute care units called the Accountable Care Unit (ACU). The ACU emphasizes care coordination through structured interdisciplinary bedside rounds (SIBR), geographic concentration of attending physicians’ panel on a single unit, unit-level performance reporting, and physician-nurse co-leadership within the ACU.

Methods

A 500+ bed teaching hospital with a level I trauma center in an urban setting within a Midwestern city recently implemented the ACU model on 7 inpatient units. Taking advantage of an implementation schedule that staggered ACU adoption on these units over nine months (May 2017 – January 2018), a two-way fixed effects specification is used to assess the effects of ACU adoption on LOS, excess days, direct cost, direct supply cost, 30-day readmission, and mortality. Thirteen units that did not adopt the ACU model were included in the analysis as controls. All inpatient admissions taking place between October 1, 2016 and August 31, 2018 that met inclusion criteria were used in the analysis (n = 27,900).

Findings

Units that implemented the ACU model realized a 0.583 (s.e. = 0.168; p = 0.003) day reduction in ALOS, a 0.679 (s.e. = 0.159, p = 0.000) day reduction in excess days, a 7.3% (s.e. = 0.037; p = 0.056) reduction in total direct cost, and a 13.7% (s.e. = 0.071; p = 0.052) reduction in direct supply costs with no change to 30-day readmission or mortality rates. Furthermore, patients discharged to a skilled nursing facility (SNF) saw even greater benefits from ACU implementation: 1.745 (s.e. = 0.424; p = 0.001) day reduction in ALOS, 1.800 (s.e. = 0.446; p = 0.001) day reduction in excess days, 17.1% (s.e. = 0.056; p = 0.004) reduction in total direct cost, and a 17.9% (s.e. = 0.087; p = 0.036) reduction in direct supply costs. Effectiveness also differed by unit: patients discharged from the medical oncology unit saw greatest benefits of ACU implementation.

Conclusions

The ACU model was able to reduce resource utilization for inpatient acute care units through reduced LOS and cost while maintaining high quality care as measured by readmission and mortality rates. Clinically complex patients, such as those discharged to a SNF, may realize the most benefit from policies like the ACU. The success of this model suggest that care coordination policies could be an effective way to address rising costs in the most expensive sector of the US healthcare system. Future work should explore in greater detail the mechanisms through which care coordination achieves these results.