Association of a Care Coordination Model with Healthcare Costs and Utilization

Berkowitz SA, Parashuram S, Rowan K, et al
Source: JAMA Netw Open
Publication Year: 2018
Patient Need Addressed: Care Coordination/Management
Population Focus: Complex care, Medicaid beneficiaries
Intervention Type: Partnership, Service redesign
Study Design: Pre-post with Comparison Group
Type of Literature: White

IMPORTANCE:  The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland.

OBJECTIVE:  To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending.

DESIGN, SETTING, AND PARTICIPANTS:  Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score–weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score–weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score–matched comparison group of local residents.

INTERVENTIONS: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations.
Main Outcomes and Measures  Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants.

RESULTS:  The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group’s Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group’s Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group’s Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings.

CONCLUSIONS AND RELEVANCE:  A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

Insights Results

Overview of programs

  • Johns Hopkins Community Health Partnership (J-CHiP) is a care coordination initiative aimed at improving challenges patients with high social needs in the Baltimore-area face with regards to streamlined care coordination. Results from J-CHiP suggests that a care coordination model that includes separate but complementary bundles of intervention strategies (i.e., ACI and CI interventions) in an urban academic environment can be associated with improvements in utilization and cost indices
  • J-CHiP program components: 1) Bundle of interventions deployed in 2 acute care East Baltimore hospitals (Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center), with additional focus on patients discharged to skilled nursing facilities (SNFs); and 2) A care management model embedded in ambulatory primary care sites located in the community
  • ACI intervention was deployed across 35 inpatient units and included: 1) Early screen for discharge planning to predict service needs following discharge; 2) Daily multidisciplinary unit-based rounds to review goals and priorities of care; 3) Patient education using tablet-based modules; 4) Enhanced medication management; 5) Telephone follow-up after discharge by nurses staffing a patient access; and 6) Skilled home care, remote patient monitoring, and/or skilled nurse transition guide for high risk patients
    Acute Care Intervention
  • ACI results from 13,921 beneficiary-episodes for Medicaid patients resulted in significant reduction in aggregate cost of care was $59.8 million ($4295 per beneficiary-episode), which was associated with reductions in outpatient care and acute care inpatient costs. Hospitalization rate increased by 49 per 1,000 beneficiary episodes, while ED rates were reduced by 133 per 1,000 beneficiary-episodes and practitioner follow-up visits were reduced by 70 and 182 per 1,000 beneficiary-episodes for 7-day and 30-day visits respectively
    Community Intervention
  • Embedded at 8 ambulatory sites and used risk prediction models to identify and target Medicare and Medicaid patients at greatest risk for hospitalization. 2 community organizations – Sisters Together and Reaching and Men and Families Together – hired and trained an additional nurse care manager and team of community health workers to supplement those already trained by Hopkins. Men and Families together used neighborhood-base support navigators to provide outreach and support services to residents
  • Results from 2,532 Medicaid beneficiaries demonstrated significant aggregate total cost-of-care reduction of $24.4 million (average savings of $1643 per beneficiary per quarter), and reductions of 33 hospitalizations, 51 ED visits, 36 30-day readmissions, and 7 avoidable hospitalizations per 1,000 beneficiaries