Mathematica, Oakland, California
Mathematica, Oakland, California.
Ann Fam Med. 2023 Jul-Aug;21(4):313-321. doi: 10.1370/afm.2992.
Despite evidence suggesting that high-quality primary care can prevent unnecessary hospitalizations, many primary care practices face challenges in achieving this goal, and there is little guidance identifying effective strategies for reducing hospitalization rates. We aimed to understand how practices in the Comprehensive Primary Care Plus (CPC+) program substantially reduced their acute hospitalization rate (AHR) over 2 years.
We used Bayesian analyses to identify the CPC+ practice sites having the highest probability of achieving a substantial reduction in the adjusted Medicare AHR between 2016 and 2018 (referred to here as AHR high performers). We then conducted telephone interviews with 64 respondents at 14 AHR high-performer sites and undertook within- and cross-case comparative analysis.
The 14 AHR high performers experienced a 6% average decrease (range, 4% to 11%) in their Medicare AHR over the 2-year period. They credited various care delivery activities aligned with 3 strategies for reducing AHR: (1) improving and promoting prompt access to primary care, (2) identifying patients at high risk for hospitalization and addressing their needs with enhanced care management, and (3) expanding the breadth and depth of services offered at the practice site. They also identified facilitators of these strategies: enhanced payments through CPC+, prior primary care practice transformation experience, use of data to identify high-value activities for patient subgroups, teamwork, and organizational support for innovation.
The AHR high performers observed that strengthening the local primary care infrastructure through practice-driven, targeted changes in access, care management, and comprehensiveness of care can meaningfully reduce acute hospitalizations. Other primary care practices taking on the challenging work of reducing hospitalizations can learn from CPC+ practices and may consider similar strategies, selecting activities that fit their context, personnel, patient population, and available resources.
尽管有证据表明高质量的初级保健可以预防不必要的住院治疗，但许多初级保健实践在实现这一目标方面面临挑战，而且几乎没有指导如何确定降低住院率的有效策略。我们旨在了解综合初级保健加（CPC+）计划中的实践如何在两年内大幅降低其急性住院率（AHR）。
我们使用贝叶斯分析来确定 CPC+实践站点在 2016 年至 2018 年期间实现调整后的医疗保险 AHR 大幅降低（这里称为 AHR 高绩效者）的可能性最高。然后，我们对 14 个 AHR 高绩效者的 64 名受访者进行了电话访谈，并进行了案例内和案例间比较分析。
14 个 AHR 高绩效者在两年期间经历了平均 6%的 Medicare AHR 下降（范围为 4%至 11%）。他们认为各种与降低 AHR 的 3 种策略一致的护理提供活动是导致 AHR 降低的原因：（1）改善并促进对初级保健的及时获得；（2）识别有住院高风险的患者，并通过强化护理管理满足其需求；（3）扩大实践地点提供的服务广度和深度。他们还确定了这些策略的促进因素：通过 CPC+获得增强的支付、先前的初级保健实践转型经验、使用数据为患者亚组确定高价值活动、团队合作以及对创新的组织支持。
AHR 高绩效者观察到，通过以实践为驱动、有针对性地改变获得护理、护理管理和护理的全面性来加强当地初级保健基础设施，可以显著降低急性住院率。其他承担降低住院率挑战性工作的初级保健实践可以从 CPC+实践中学习，并可以考虑类似的策略，选择适合其背景、人员、患者群体和可用资源的活动。
