Are general practitioner hospitals cost-saving? Evidence from a rural area of Norway

OBJECTIVE: We aimed to determine whether general practitioner GP hospitals, compared with alternative modes of health care, are cost- saving. METHODS: Based on a study of admissions (n = 415) to fifteen GP hospitals in the Finnmark county of Norway during 8 weeks in 1992, a full 1-year patient throughput in GP hospitals was estimated. The alternative modes of care (general hospital, nursing home or home care) were based on assessments by the GPs handling the individual patients. The funds transferred to finance GP hospitals were taken as the cost of GP hospitals, while the cost of alternative care was based on municipality and hospital accounts, and standard charges for patient transport. RESULTS: The estimated total annual operating cost of GP hospitals was 32.2 million NOK (10 NOK = 1 Pound) while the cost of alternative care was in total 35.9 million NOK. Sensitivity analyses, under a range of assumptions, indicate that GP care in hospitals incurs the lowest costs to society. CONCLUSION: GP hospitals are likely to provide health care at lower costs than alternative modes of care.      

Cost and care models for acutely ill nursing home residents in Germany: the example of pneumonia

Background

Hospitalisation of acutely ill nursing home residents is associated with health risks such as infections, complications, or falls, and results in high costs for the health care system. Taking the case of pneumonia, nursing homes generally can ensure care according to guidelines.

Aim

Extrapolation of overall expenditures for the German statutory health insurance system from the hospitalisation of nursing home residents with respiratory infection/pneumonia; developing alternative cost scenarios to compare nursing home care with hospital care in consideration of patients’ condition.

Methods

Data provided by health insurance funds were extrapolated to the German statutory health insurance system and weighted via German-DRG case values. Care processes (hospital vs. nursing home) were modelled, and treatment steps were divided into cost categories. The patient’s condition was standardised via the Barthel Index.

Results

Total expenditures of € 163.3 million were incurred for inpatient care of nursing home residents transferred to hospitals for respiratory infection/pneumonia in 2013 in Germany. Process modelling reveals lower direct costs for nursing home care as well as better development of patients’ condition. Looking at operators of nursing homes, both care scenarios necessitate additional services without reimbursement.

Conclusion

Expenditure projections for the hospital care of nursing home residents with pneumonia reveal high saving potential. Avoidance of hospital admission serves to considerably reduce the insurers’ expenditures but also the duration and severity of illness. The study illustrates economic incentive structures for health care providers and indicates courses of action for health policy and nursing homes operators.

     

A cost-minimisation study of alternative discharge policies after hip fracture repair

It is widely assumed that health care costs can be reduced considerably by providing care in appropriate health care institutions without unnecessary technological overhead. This assumption has been tested in a prospective study. Conventional discharge after hip fracture surgery was compared with an early discharge policy in which patients were discharged to a nursing home with specialised facilities for rehabilitation. We compared costs for both strategies from a societal perspective, using comprehensive and detailed data on type of residence and all kinds of medical consumption during a 4-month follow-up period.As expected, early discharge reduced the hospital stay (with 13 days, p=0.001). More patients were discharged to a nursing home (76% versus 53%). Total medical costs during follow-up were reduced from an average of euro;15338 to euro;14281, representing relatively small and not significant savings (p=0.3). There are two explanations for this unexpected result. First, costs incurred by hip fracture patients were relatively less while in hospital. Hence, nursing home costs almost equalled hospital costs per admission day. Second, compared with the conventionally discharged group early discharged patients were subjected to more medical procedures during the first post-operative days. We conclude that: (1). early discharge shifted rather than reduced costs; (2). the details of costing have a major influence on the cost-effectiveness of alternative discharge policies.     

'Wrong beds', a continuous misunderstanding?

The run-off of hospital patients to nursing homes is insufficient. In the hospital that was examined 10% of the available beds were occupied by patients who belonged in nursing homes. In the region concerned 3% of the available nursing home beds would be sufficient to solve this problem. For human and financial considerations reservation of nursing beds for this purpose is to be preferred to the current temporary provision that labels the hospital bed financially as a nursing home bed.     

Associations Between Psychiatric Inpatient Bed Supply and the Prevalence of Serious Mental Illness in Veterans Affairs Nursing Homes

Objectives. We assessed whether reductions in inpatient psychiatric beds resulted in transinstitutionalization to nursing home care of patients with serious mental illness (SMI) within the Veterans Health Administration (VHA).Methods. We assessed trends in national and site-level inpatient psychiatric beds and nursing home patient demographics, service use, and functioning from the VHA National Patient Care Database, VHA Service Support Center Bed Control, and VHA Minimum Data Set. We estimated nursing home admission appropriateness using propensity score analyses based on Michigan Medicaid Nursing Facility Level of Care Determinations ratings.Results. From 1999 to 2007, the number of VHA inpatient psychiatric beds declined (43 894–40 928), the average inpatient length of stay decreased (33.1–19.0 days), and the prevalence of SMI in nursing homes rose (29.4%–43.8%). At site level, psychiatric inpatient bed availability was unrelated to SMI prevalence in nursing home admissions. However, nursing home residents with SMI were more likely to be inappropriately admitted than were residents without SMI (4.0% vs 3.2%).Conclusions. These results suggest the need for increased attention to the long-term care needs of individuals with SMI. Additional steps need to be taken to ensure that patients with SMI are offered appropriate alternatives to nursing home care and receive adequate screening before admission to nursing home treatment.Over the past half century, the locus of psychiatric care has shifted from long-term inpatient psychiatric hospitals to community-based outpatient care settings,1 with this “deinstitutionalization” movement resulting in a sharp decline in state psychiatric hospital beds.2 This movement is regarded as a “disaster of the past,”3 in part because of the inadequacy of outpatient services to meet the needs of symptomatic psychiatric patients.3,4 In the absence of adequate community-based services, deinstitutionalization in name often resulted in transinstitutionalization in practice, as symptomatic patients were shifted to other institutional settings, such as general hospitals and nursing homes.1Research investigating transinstitutionalization has mixed results. A 3-year follow-up of patients discharged from a state psychiatric hospital found rates of more than 20% admission to community inpatient psychiatric units, with an average of more than 75 yearly inpatient days per patient.5 Similarly, a large-scale longitudinal evaluation of the Canadian mental health system found that reductions in inpatient psychiatric beds were associated with increased utilization of general hospital psychiatric beds, a pattern that continued for more than 2 decades until community mental health services expanded to meet the needs of psychiatric patients.6 However, another evaluation of discharged state psychiatric patients found decreased rates of postdischarge jail and general hospital psychiatric unit utilization relative to the use of these services during the time that patients received state psychiatric care.7There has been limited investigation into transinstitutionalization to community nursing home settings. The only large-scale study of transinstitutionalization to nursing home care was conducted in Norway, in which the effects of downsizing psychiatric hospitals were evaluated for more than 50 years. During the first 2 decades, there was evidence for transinstitutionalization because patients previously treated in state-run psychiatric facilities were enrolled in increasing numbers in nursing homes. Similar to the Canadian evaluation, this pattern continued until community-based mental health services evolved to meet the needs of these psychiatric patients, with transinstitutionalization to nursing home care ending by the early 1970s.8Many nursing homes are unable to offer the specialized treatment required by patients discharged from state mental hospitals.9 Concerns about such shortcomings led to the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). This legislation set guidelines for standardized mental health screening and treatment within nursing homes, with the goal of reducing inappropriate admissions and improving the care of patients with psychiatric conditions already enrolled in nursing home care. Although OBRA-87 had positive effects,10,11 it also has its shortcomings.12Despite OBRA-87, available data suggest that nursing homes continue to have sizeable proportions of residents with serious psychiatric disorders. In a study of more than 9000 Veterans Health Administration (VHA) nursing home residents, nearly one fifth of residents (17.9%) met criteria for serious mental illness (SMI).13 Similar levels of SMI prevalence were found in nursing home populations outside of the VHA.14,15 It is unclear at this time whether these patients were placed appropriately into nursing home care or inappropriately admitted in the absence of adequate inpatient psychiatric services.Reductions in psychiatric inpatient bed availability have continued in recent years. There has been a national reduction from 99 223 psychiatric beds in 1990 to 55 576 beds in 2009 within hospitals.16 Meanwhile, nursing home bed availability has increased. The number of available beds within skilled nursing homes increased from 512 107 in 1990 to more than 1.5 million in 2009.16Transinstitutionalization demonstrates the interconnectedness of institutional settings.17 To date, however, few studies assessed relationships between psychiatric inpatient and long-term care services in a single health system. Although transinstitutionalization to nursing homes was observed in previous decades, it is unclear whether these patterns continued in recent years. This study examined trends in psychiatric inpatient resources in the VHA health system, in association with VHA-funded nursing home care, which includes both VHA-owned nursing homes (which are today known as Community Living Centers) and VHA-contracted community nursing homes. To further evaluate the potential for transinstitutionalization between these settings, changes in the process of inpatient psychiatric care were tracked to evaluate evidence for unmet psychiatric needs. This study had 3 primary objectives: (1) to assess trends in VHA inpatient psychiatric beds from fiscal year 1999 (FY99) to FY07, (2) to assess relationships between changes in VHA inpatient psychiatric bed supply and the prevalence of SMI in VHA nursing home residents, and (3) to assess potential relationships between VHA psychiatric inpatient bed availability and the appropriateness of VHA nursing home admissions for patients with SMI.     

Carers' reflections on nursing home and NHS long-stay care for elderly patients

The aim of this study was to compare the perceptions of carers of elderly long-stay care patients who are now in nursing homes in three health districts in a former Regional Health Authority and in remaining long-stay geriatric National Health Service (NHS) wards. One hundred and ninety-eight nursing home carers (78%) and 128 NHS carers (83%) were interviewed by telephone, using a semi-structured questionnaire and open questions. The impact of caring at home was shown to be greater on NHS than on nursing home carers. Most were satisfied with the care, staff and atmosphere of the nursing home or hospital. Nursing homes were perceived to offer better ‘hotel’ facilities and a more pleasant environment. They were seen as better at respecting patients' privacy. The NHS was regarded as superior in offering clinical and rehabilitative services. Most participants thought the institution was the right place for their relative, although in general, it was thought to be better to care for elderly people at home. ‘Care in the community’ was supported, but carers were realistic about alternatives when informal care ceased to be a reasonable option. There was little ‘choice’ between public and private sector care. For many patients, entry into the institution followed directly from an acute hospital admission. The only choice was between care in a long-stay facility or remaining at home, with the patient becoming increasingly dependent and the carer becoming increasingly unable to cope. The formal aspect of community care should be to be organized rationally and accepted as a valid response to the needs of some dependent elderly patients and their carers.     

Los problemas de salud también explican la utilización de servicios sociales en atención domiciliaria

ObjectiveTo identify which social and health variables are associated with receiving social services in patients included in home care programmes with the implementation of the Dependence Law.DesignCross-sectional study.Setting72 primary health care teams in Catalonia.PatientsPatients over 64 years old with chronic diseases in home care programmes in Catalonia.MeasurementsHealth status variables: Charlson, Barthel, Pfeiffer, Braden and Gijon, data from their carer (Zarit), self perception of health (SF-12), health professional visits, as well as: emergency visits, temporary admissions, and final results such as death or definitive admission in a nursing home or a hospital.ResultsA total of 1068 patients were included, 46.8% of the patients received some kind of social service, public or private. We observed that the variables related to receive some kind of social services are: high dependence (Barthel test), pressure sores and home care rehabilitation. Barthel test is highly associated with having social problems (Gijon test), living without an informal carer, more than 2 GP visits and having additional private health care.ConclusionsTo be more fair, the evaluation of the provisions of the Dependence Law should also consider the health status of the patient. With the implementation of this law we can observe difficulties in access to social services for middle class patients. These patients do not have access to public social assistance and cannot pay for a private one. Social services are still an alternative to family care.     

Association Between Clinician Specialization in Nursing Home Care and Nursing Home Clinical Quality Scores

ImportanceWhile the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%.ObjectivesTo measure the association between regional trends in clinician specialization in nursing home care and nursing home quality.DesignRetrospective cross-sectional study.Setting and ParticipantsPatients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016.MeasuresClinician specialization in nursing home care for 2012–2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013–2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression.ResultsAn increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use.Conclusions and ImplicationsHigher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.     

Determinants of hospital-to-nursing home placement delays: a pilot study.

Estimates of hospital-to-nursing home placement delays have always been varied, and given Medicare's new Prospective Payment System (PPS) based on diagnosis-related groups (DRGs), they are likely to have changed again. Theory and previous research suggest that four patient characteristics are the main causes of delays: Medicaid as the patient's nursing home payer source; need for heavy care due to major physical or mental problems; admission to the hospital from a nursing home; and lack of social support. A pilot study of all 1,016 elderly awaiting nursing home placement in two admission cohorts (pre- and post-PPS) from the three largest hospitals in the county surrounding Charlotte, North Carolina--where nursing home beds are in short supply--indicates that other factors are more important. While most placements were delayed, delays were short. Multiple regression results show that Medicaid patients' delays were only about a day longer than those of private-pay patients. Of the many heavy-care conditions studied, only three were associated with delay. Patients without social support and patients admitted from a nursing home, discharged to a hospital-affiliated facility, or placed after PPS had shorter delays. Long delays were found among patients who had applied for Medicaid coverage but had not yet been certified as financially eligible. Nonwhites and males were also delayed. These findings, if replicated in other areas with perceived nursing home bed shortages, appear to have important implications not only for the usefulness of nursing home case-mix reimbursement and subacute levels of nursing home care, but for nursing home bed-need estimates, too, as well as for Medicaid eligibility determination practices and civil rights law enforcement.     

Waiting for placement: an exploratory analysis of determinants of delayed discharges of elderly hospital patients.

This article examines the causes of delayed hospital discharge for 3,111 patients waiting for alternative placement in 80 North Carolina acute care general hospitals during May 1989. Almost all of the patients were elderly: their average age was 77. Delay is defined as the period between the day a patient was judged medically ready for discharge by a discharge planner and the day the patient was discharged (or May 31 if unplaced). The average delay was 16.7 days. The policy-relevant patient characteristics associated with delay are requirement for heavy care, race, source of reimbursement, and whether or not there was a financial problem in arranging discharge. The patient's age and whether or not a problem with behavior or family cooperativeness was noted also were predictors. Along with patient characteristics, hospital features such as bed size, occupancy rate, and total revenues were correlated with delay. Local nursing and rest home (domiciliary) bed supply were insignificant predictors, possibly because of their limited variance: the number of nursing home beds in all North Carolina counties is below the national mean; the number of rest home beds exceeds it. The conclusion reached is that the delay problem warrants more intensive analysis, particularly regarding financial problems encountered at discharge, and race. Guidelines for such an endeavor are provided. Further, there is a need to recognize the increasing preponderance of a new type of heavy care patient via more appropriate reimbursement levels and "transitional care" services.     

The effect of competition on nursing home expenditures under prospective reimbursement.

The for-profit nursing home's incentive to minimize costs has been maligned as a major cause of the quality problems that have traditionally plagued the nursing home care industry. Yet, profit-maximizing firms in other industries are able to produce products of adequate quality. In most other industries, however, firms are constrained from reducing costs to the point where quality suffers by the threat of losing business to competing firms. In the nursing home industry, competition for patients often does not exist because of the shortage of nursing home beds. As a result, one would expect that nursing homes located in areas where there is excess demand would spend less on patient care than homes located where the bed supply is relatively abundant. This hypothesis is tested using Wisconsin data from 1983. It is found that, in counties with relatively tight bed supplies, an additional empty bed in all the homes in the county will force each home to increase expenditures by $.62 per day for each patient in the home. Overall, the average nursing home located in underbedded markets would spend $5.12 more per patient day or about $240,000 more annually (in 1983 dollars) if it were located in a market where it was forced to compete for patients. The implications for public policy are discussed.     

Direct Admission to Intermediate Care for Older Adults With Reactivated Chronic Diseases as an Alternative to Conventional Hospitalization

BackgroundWhen reactivations of chronic diseases cannot be managed at home, postacute intermediate-care geriatric units (ICGUs) might provide adequate and specialized support to primary care, based on comprehensive geriatric assessment and rehabilitation.ObjectivesTo explore if direct admission to ICGUs of older adults with reactivated chronic diseases or acute common conditions superimposed to chronic diseases might be an alternative clinical pathway to conventional acute hospitalization followed by intermediate care rehabilitation.MethodsQuasiexperimental pilot study. We compared characteristics at admission and outcomes at discharge between two groups admitted to our ICGU: the first one admitted directly, and the second one admitted to complete treatment and rehabilitation after discharge from acute hospital.ResultsSixty-five patients from the same primary care area (mean age ± SD 85.6 ± 7.2, 66% women) were admitted to the ICGU for the same main diagnostics, mainly reactivation of heart failure and chronic obstructive pulmonary disease: 32 directly from home (DA) and 33 following acute hospital discharge (HD). Baseline clinical, functional, and social characteristics, as well as outcomes at discharge, including mortality and acute transfers, were comparable between groups. Global length of stay was significantly higher in HD, compared with DA (60.8 ± 26.6 vs 38.4 ± 23 days, P < .001).ConclusionsFrom our preliminary results, direct admission to geriatric intermediate care units might represent a potential alternative to acute hospitalization for selected older patients.     

Trajectories Over the First Year of Long-Term Care Nursing Home Residence

Objectives

To describe the trajectories in the first year after individuals are admitted to long-term care nursing homes.

Hospital discharge decisions, health outcomes, and the use of unobserved information on case-mix severity.

Although implementation of the Medicare prospective payment system has been accompanied by significant decreases in hospital length of stay, the early discharge of some patients may lead to worse health outcomes, particularly if sufficient aftercare services following hospitalization are not available. This article develops an empirical model of the relationship between the choice of length of stay and patient outcome. The model incorporates information on the severity of a patient's medical condition known by the physician who chooses length of stay for a patient but generally not known by a researcher interested in the factors that affect length of stay and health outcome. Joint estimation of equations for length of stay and health outcome controls for unmeasured aspects of case severity that affect both variables. The ratio of nursing home beds to Medicare enrollees in the county is included as an exogenous variable in both equations to assess whether variation in nursing home bed availability is correlated with length of stay or health outcome. The model is estimated using billing data for Medicare patients admitted with congestive heart failure to New Jersey hospitals during 1982 and 1983. Two measures of outcome are used: (1) a discrete measure of survival time following admission, and (2) a categorical measure of whether or not the patient was discharged dead or died within six months after discharge. Empirical results show no evidence that longer lengths of stay for congestive heart failure patients lead to lower postadmission mortality. However, greater availability of nursing home beds may reduce length of stay and may shift the provision of terminal care away from a hospital setting. Therefore, policies to expand the nursing home bed supply may enable further decreases in hospital length of stay without deleterious effect on patient outcome.     

Efficiency of Institutional Long Term Care and Annual Demands for Placement

The objective of this study was to determine the efficiency of and annual demands for institutional long term care placement in the St. John's region. The study population comprised all applicants assessed for institutional long term care through the Community Health St. John's Region Single Entry System in 1995-96. The outcome measures used for the study included estimates of client resource utilization employing the RUGs III and Alberta Resident Classification System; hospital beds occupied; time to placement; and annual demands on long term care.The study concludes that objective criteria for admission to supervised care and nursing home care may help reduce the number of inappropriate placements (thus maximizing the use of existing nursing home beds) and decrease annual demands. Investment in alternatives to nursing home care for those with modest disability is suggested.     

Intermediate care. Bed spread

A health authority which has been using beds in independent nursing homes as alternatives to hospital for older people since 1997 has found this a satisfactory model of care. Initially the beds were used for terminal care only. Last winter the scheme was extended to provide intermediate care. The scheme uses a maximum of five beds for terminal care in one nursing home at any one time. The scheme is thought to have saved some 2,000 bed days each year. The length of stay has been reduced and now stands at 33 days.     

Rehabilitation and convalescent hospital stay in New South Wales: an analysis of 3,979 women aged 75+

Objectives : With a rapidly ageing population, it is imperative to examine health service costs and plan appropriately for the future. This paper determines the factors related to extended hospital stay for ‘Rehabilitation’ or ‘Convalescence’, as defined by ICD‐10 coding, in acute hospital settings for older women in New South Wales, Australia. Methods : Participants were from the 1921–26 cohort of the Australian Longitudinal Study on Women's Health. For this analysis, self‐reported survey data were linked to the NSW Admitted Patient Data Collection and the National Death Index. Results : Of the 3,979 participants, 88% had a hospitalisation in the 13‐year observation period, and 37% had either a rehabilitation or convalescence admission in an acute hospital setting. In the multivariate model, living in a regional or remote area was the only variable positively associated with having a rehabilitation or convalescence hospitalisation (AOR=1.58 [1.33, 1.87]). Conclusions : Area of residence is the determining factor for rehabilitation or convalescence hospital admissions. These long stay admissions are not necessarily inappropriate, but due to a lack of other non‐acute care options. Implications for public health : Increased availability of rehabilitation and respite care in non‐acute settings will not only improve older patient care, but will also reduce the burden on acute hospitals.     

The costs and service implications of substituting intermediate care for acute hospital care.

Intermediate care is part of a package of initiatives introduced by the UK Government mainly to relieve pressure on acute hospital beds and reduce delayed discharge (bed blocking). Intermediate care involves caring for patients in a range of settings, such as in the home or community or in nursing and residential homes. This paper considers the scope of intermediate care and its role in relation to acute hospital services. In particular, it develops a framework that can be used to inform decisions about the most cost-effective care pathways for given clinical situations, and also for wider planning purposes. It does this by providing a model for evaluating the costs of intermediate care services provided by different agencies and techniques for calibrating the model locally. It finds that consistent application of the techniques over a period of time, coupled with sound planning and accounting, should result in savings to the health economy.     

Impact of long-term home care on hospital and nursing home use and cost.

This article reports the long-range impact of a long-term home care program in Chicago on hospital and nursing home use and on overall health care costs over four client-years of observation. The evaluation utilized a quasi-experimental design with a comparison group composed of clients who received home-delivered meals. The health services utilization experience of consecutively accepted treatment (N = 157) and comparison group (N = 156) subjects was monitored for 48 client-months following acceptance to care. Imputed costs were then assigned to each type of care measured. Findings include a significantly lower risk of permanent admission to sheltered and intermediate-level nursing home care in the treatment group but no difference in risk of permanent admission to skilled-level nursing home care. Despite savings in low-intensity nursing home days, preliminary findings indicate that total costs of care were 25 percent higher in the treatment group. However, these costs are accompanied by significant quality-of-life benefits in the treatment group (reported elsewhere).     

Should Medicare compensate hospitals for administratively necessary days?

Days that a patient remains in a hospital due to inability to secure nursing home placement are termed administratively necessary days (ANDs). Some hospitals under Medicare's prospective payment system have incurred discharge delays of this kind. Nursing home bed supply is one major problematic factor; others include adequacy of Medicare nursing home reimbursement rates relative to nursing home costs in an area, the willingness of facilities in an area to serve those needing skilled care, and stringency of relevant Medicaid reimbursement policy. Two promising approaches for dealing with ANDs are increasing nursing home reimbursement rates, and adjusting Medicare payments for exceptionally long-staying patients or those requiring exceptionally intensive care in hospitals.