Table 3.
Exposure and Effect of Care Coordination Strategies on Preventable Hospitalizations and Depression in ACOs, 2015
| Variable | All (N=73,690) Mean (SD) | NH white (N=55,148) OR (p-value) | NH African American (N=9,373) OR (p-value) |
|---|---|---|---|
| Total care coordination strategies (0–12) Individual care coordination strategies | 5.84 (3.21) | 1.01 (0.403) | 0.98 (0.089) |
| Hospitalists for medical/surgical inpatients | 0.98 (0.15) | 0.76 (0.008) | 0.72 (0.197) |
| Medication reconciliation as part of an established plan of care | 0.89 (0.31) | 1.02 (0.74) | 0.96 (0.719) |
| Provision of visit summaries to patients as part of all outpatient encounters and scheduling of follow up visit and/or specialty referrals at the time of the initial encounter | 0.56 (0.5) | 1 (0.911) | 0.9 (0.202) |
| Telephonic outreach to discharged patients within 72 hours of discharge | 0.55 (0.5) | 0.99 (0.685) | 0.77 (0.001) |
| Disease management programs for one or more chronic care conditions (e.g., asthma, diabetes, COPD) | 0.46 (0.5) | 1.13 (0.001) | 1.08 (0.369) |
| Chronic care management processes or programs to manage patients with high volume, high cost chronic diseases | 0.43 (0.5) | 1.09 (0.017) | 0.81 (0.01) |
| Post-hospital discharge continuity of care program with scaled intensiveness based upon a severity or risk profile for adult medical-surgical patients in defined diagnostic categories or severity profiles | 0.4 (0.49) | 0.94 (0.116) | 0.78 (0.008) |
| Prospective management of patients at high risk for poor outcomes or extraordinary resource use by experienced case managers | 0.35 (0.48) | 1.08 (0.039) | 1.03 (0.704) |
| Nurse case managers whose primary job is to improve the quality of outpatient care for patients with chronic diseases (e.g., asthma, CHF, depression, diabetes) | 0.33 (0.47) | 0.95 (0.207) | 0.8 (0.004) |
| Assignment of case managers for outpatient follow-up to patients at risk for hospital admission or readmission | 0.32 (0.47) | 1.02 (0.692) | 0.99 (0.93) |
| Arrangement of home visits by physicians, advanced practice nurses, or other professionals for homebound and complex patients for whom office visits constitute a physical hardship | 0.31 (0.46) | 1.03 (0.48) | 1.11 (0.262) |
| Use of predictive analytic tools to identify individual patients at high risk for poor outcomes or extraordinary resource use | 0.27 (0.45) | 1.01 (0.869) | 0.93 (0.411) |
Notes: Total sample (N=73,690) includes discharges for adult adults with depression from 86 hospitals affiliated with an accountable care organization (ACO) in 11 states (Florida, Arizona, Colorado, Kentucky, Maryland, North Carolina, New Jersey, Oregon, Rhode Island, Washington, and Wisconsin). Potentially preventable hospitalizations were measured using the AHRQ algorithm for any of the following chronic condition Prevention Quality Indicators (PQIs) : uncontrolled diabetes (PQI 14), diabetes related short-term and long-term complications (PQI 1, PQI 3); chronic obstructive pulmonary disease or asthma (PQI 5 and PQI 15), hypertension (PQI 7), and heart failure (PQI 8). Comparison group is all other patients. Boldface indicates statistical significance (p<0.05).
Sources: 2015 HCUP SID, 2015 AHA annual survey; and the 2015 AHA Care Systems and Payment Survey.
ACO, accountable care organization; NH, non-Hispanic; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; AHRQ, Agency for Healthcare Research and Quality; HCUP, Healthcare Cost and Utilization Project; SID, State Inpatient Databases; AHA, American Hospital Association.