Ruiz Sarah, Snyder Lynne Page, Giuriceo Katherine, Lynn Joanne, Ewald Erin, Branand Brittany, Parashuram Shriram, Loganathan Sai, Bysshe Tyler
National Institute on Disability, Independent Living, and Rehabilitation Research, Administration for Community Living, Washington, District of Columbia.
NORC at the University of Chicago, Health Care Department, Bethesda, Maryland.
Innov Aging. 2017 Nov 20;1(2):igx021. doi: 10.1093/geroni/igx021. eCollection 2017 Sep.
Care coordination and palliative care supports are associated with reduced anxiety, fewer hospital admissions, and improved quality of life for patients and their families. Early palliative care can result in savings in the end-of-life period, but there is limited evidence that larger-scale models can improve both utilization and the cost of care. Three models that received Health Care Innovation Awards from the Centers for Medicare & Medicaid Services aimed to improve quality of care and reduce cost through the use of innovative care coordination models. This study explores the total cost of care and selected utilization outcomes at the end-of-life for these innovative models, each of which enrolled adults with multiple chronic conditions and featured care coordination with advance care planning as a component of palliative care. These included a comprehensive at-home supportive care model for persons predicted to die within a year and two models offering advance care planning in nursing facilities and during care transitions.
We used regression models to assess model impacts on costs and utilization for high-risk Medicare beneficiaries participating in the comprehensive supportive care model ( = 3,339) and the two care transition models ( = 587 and = 277) who died during the study period (2013-2016), relative to a set of matched comparison patients.
Comparing participants in each model who died during the study period to matched comparators, two of the three models were associated with significantly lower costs in the last 90 days of life ($2,122 and $4,606 per person), and the third model showed nonsignificant differences. Two of the three models encouraged early hospice entry in the last 30 days of life. For the comprehensive at-home supportive care model, we observed aggregate savings of nearly $19 million over the study period. One care transition model showed aggregate savings of over $500,000 during the same period. Potential drivers of these cost savings include improved patient safety, timeliness of care, and caregiver support.
Two of the three models achieved significant lower Medicare costs than a comparison group and the same two models also sustained their models beyond the Centers for Medicare & Medicaid Services award period. These findings show promise for achieving palliative care goals as part of care coordination innovation.
护理协调与姑息治疗支持与患者及其家属焦虑减轻、住院次数减少以及生活质量提高相关。早期姑息治疗可在临终阶段节省费用，但仅有有限证据表明大规模模式能改善医疗服务利用情况及护理成本。三种获得医疗保险与医疗补助服务中心医疗保健创新奖的模式旨在通过采用创新护理协调模式提高护理质量并降低成本。本研究探讨了这些创新模式在临终阶段的护理总成本及选定的医疗服务利用结果，每种模式均纳入患有多种慢性病的成年人，并将护理协调与预先护理计划作为姑息治疗的一个组成部分。这些模式包括为预计一年内死亡者提供的全面居家支持护理模式，以及在护理机构和护理过渡期间提供预先护理计划的两种模式。
我们使用回归模型评估这些模式对参与全面支持护理模式（n = 3339）以及两种护理过渡模式（n = 587和n = 277）且在研究期间（2013 - 2016年）死亡的高风险医疗保险受益人的成本和医疗服务利用情况的影响，对照组为一组匹配的对照患者。
将研究期间死亡的各模式参与者与匹配的对照者进行比较，三种模式中的两种与生命最后90天的成本显著降低相关（每人分别降低2122美元和4606美元），第三种模式差异不显著。三种模式中的两种鼓励在生命的最后30天尽早进入临终关怀。对于全面居家支持护理模式，我们在研究期间观察到总计近1900万美元的节省。一种护理过渡模式在同一时期显示总计节省超过50万美元。这些成本节省的潜在驱动因素包括改善患者安全、护理及时性以及对护理人员的支持。
三种模式中的两种实现了比对照组显著更低的医疗保险成本，并且这两种模式在医疗保险与医疗补助服务中心奖励期之后仍维持其模式。这些发现显示了作为护理协调创新的一部分实现姑息治疗目标的前景。
