Researchers recently identified predictors of high-cost hospital stays related to ambulatory care-sensitive conditions (ACSCs). The highest median cost of care is related to heart failure, followed by diabetes and COPD.1
The researchers studied data for Medicaid patients and found the median cost of care for this population was $793, says Susan B. Roman, MPH, RN, lead author of the study and director of care coordination and integrated support programs with Fair Haven Community Health Care in New Haven, CT.
“We were looking at specific ACSCs because they have a higher rate of utilization and cost associated with them,” Roman explains. “We also found [being] male was an independent predictor; males of higher ages, who had various conditions, were also associated with higher costs.”
Gender, age, and an ACSC diagnosis were associated with higher costs, but race and ethnicity were not.
Roman’s purpose for the study was to improve care coordination by showing its value with certain high-cost conditions. “I was interested in moving forward to look at how we could show a return on investment,” she explains.
The researcher accomplished this. “If organizations invest in care coordination, they will see a return on investment because this group will be able to help manage symptoms,” she says.
Case managers and care coordinators also look at patients’ social determinants of health and can collaborate to affect patients’ health and well-being, she adds.
Much of Roman’s research involved the pediatric population. “I could tell you in the pediatric population what are the top 10 conditions with high utilization rates and high costs,” she says. “It’s a very small percentage of pediatric children who have higher costs, but adults are different from pediatrics.”
Targeted Coordination Reduces Costs
Investigators examined 15 months of claims data of about 8,000 patients from mid-2018 to early 2020. They studied a variety of diagnoses, including hypertension, asthma, urinary tract infections, community-acquired pneumonia, diabetes, COPD, and heart failure. They used prevention quality indicators from the Agency for Healthcare Research and Quality (AHRQ) to identify ACSCs. A high-cost episode of care — in the top quartile within a seven-day period — for an ACSC was the primary outcome.
The research demonstrates care coordination and case management efforts that target people — particularly older men — with heart failure, diabetes, and/or COPD could improve their care and reduce costs.
“Overall, in thinking about how care coordination could have an impact, I’d like to develop tools where we’re looking at these high utilizers, whether we look at risk scores or claims, and start to have robust care coordination plans that have buy-in from all providers involved with that patient or that cohort,” Roman says. “Going upstream, care coordination is what happens outside the visit, between those visits and the emergency department visits and hospitalizations. It’s where you’re really looking at improving health and well-being by impacting social determinants that [affect] well-being and getting people the services they need in the community.”
It requires ample collaboration between healthcare providers and community-based organizations. Patients served by this type of targeted care coordination often experience multiple social determinants of health issues, including homelessness and transportation issues. They also have nutrition problems.
“We have to work around their medical care with providers, asking whether they received their COVID-19 shots, their flu shots,” Roman says.
Case managers and care coordinators can help patients find stable housing and connect them with food pantries. They might help with heating and other utility problems and identify issues related to intimate partner violence.
“They help families with diagnoses and getting the services they need,” Roman says.
Providers and community-based organizations can refer patients to care coordination. When coordinators work with patients with specific health conditions, they focus on outcome measures. For example, with diabetes, they will see if a patient’s A1c levels have decreased and whether the change is directly affected by the care coordination program.
“We know if we are helping someone get the right food, they’ll get better,” Roman says.
REFERENCE
- Roman SB, Whitmire L, Reynolds L, et al. Demographic and clinical correlates of the cost of potentially preventable hospital encounters in a community health center cohort. Popul Health Manag 2021; Aug 31. doi: 10.1089/pop.2021.0169. [Online ahead of print].
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