Costs of Implementing Post-Discharge Program After Stroke

March 03, 2020

Providing comprehensive aftercare for stroke patients following discharge from the hospital can be expensive, particularly for smaller institutions, but it may still be cost-effective as insurance companies start to reimburse for such services, a new study suggests.

The costs involved in implementing and sustaining a transitional stroke care model for patients discharged home from hospitals in North Carolina were reported in a presentation by William Bayliss, MSPH, University of North Carolina's Gillings School of Global Public Health, at the recent International Stroke Conference (ISC) 2020.

The model, known as COMPASS (Comprehensive Post-Acute Stroke Services), involves close follow-up of patients by hospital staff for the first couple of months after they leave the hospital to ensure the patient receives optimum secondary preventive medication and other recommended interventions.

The average cost per hospital for the program was calculated to be $74,975 (25th to 75th percentile, $46,240 – $87,785), with cost per patient of $2861 ($735 – $3475).

Bayliss noted that the data come from a survey of 22 hospitals participating in the program and involve 1582 patients. He pointed out that positive economies of scale were seen, with average per-patient costs being lower among larger hospitals.

"Taking into account the costs of readmissions, we have estimated that the COMPASS program could lower net costs if it is able to prevent around six readmissions per hospital per year," he concluded.

The senior author of the research, Justin Trogdon, PhD, professor of health policy and management at Gillings School of Global Public Health, told Medscape Medical News that the COMPASS program was developed by healthcare professionals who were involved in stroke care at Wake Forest School of Medicine in Winston-Salem, North Carolina.

"Without such a program, aftercare for stroke patients can be very fragmented. It depends on where you live and what insurance you have," Trogdon explained. "Some patients or caregivers will be good at navigating the system, or they may have good insurance coverage that includes follow-up services, but sometimes patients are just discharged home with very little follow-up. They may have a name of someone to contact for information, but it can be up to them to make that happen.

"Our COMPASS model provides touchpoints to make sure proper aftercare happens in a more formal and structured way, keeping patients in the system after they have left hospital," he added.

CMS and other payors are starting to focus on improving care for patients discharged home and creating billing codes to allow for reimbursement specifically for his type of follow-up care, Trogdon noted.

The model includes a postacute coordinator staff member who meets with the patient and/or caregiver at discharge and presents information on medications and future appointments. The coordinator then telephones the patient or caregiver on day 2, and a follow-up appointment is scheduled 2 weeks later to check the patient's functional status. Further calls are made at 30 and 60 days.

"These calls and appointments are to make sure the patient has all the medications they need and understands how to take them and to arrange physical therapy appointments if required," Trogdon said. "The riskiest time for a stroke patient after they leave hospital is in the first 2 to 4 weeks. It is of the utmost importance that they take their secondary prevention medication and any other issues, such as blood pressure and cholesterol, are managed properly. There is often an overload of information at the hospital which patients/caregivers may not take in."

Trogdon and colleagues have previously reported some results from this project that show that hospitals were able to deliver this program, which was associated with an improvement in outcomes.

"But some hospitals had challenges to the implementation, and we wanted to look at the costs of the program and where the resources were being used the most, so we surveyed the participating hospitals for this information," he said.

Results show that the biggest expense was the initial cost of identifying eligible patients to take part in the program. "This was because patient identification was often done by hand with an administrator or nurse going through all the charts to identify and select patients," Trogdon explained.

"In future, we think this will be able to be automated with electronic databases and that part of the cost will come down significantly.

"We have found some data on the average cost of readmission, and our preliminary calculations suggest that the scheme will be cost-saving if it can prevent six patients from being readmitted per hospital," he stated. "We don't know yet how many readmissions the scheme will prevent, but we will continue to collect data, and hopefully will we obtain more information on downstream costs and savings.

"I hope people will see this scheme as realistic and achievable. As well as affecting patient outcomes and quality of life, readmissions hurt the bottom line, and ultimately insurance reimbursements may be at risk if the readmission rate is too high, so there is also a financial incentive to do this," he added.

Commenting on the study for Medscape Medical News, Jeremy Payne, MD, medical director of the stroke program at Banner University Medical Center, Phoenix, Arizona, said the COMPASS program was "impressive."

"We struggle a lot with the transition after hospitalization for stroke patients," Payne said. "It is often quite a mess. Some patients have no follow-up at all after discharge. The primary care doctor is often unaware of what has happened, and some patients don’t even have a primary care doctor. I think the COMPASS approach will be very helpful. It is hard to pin down costs of what is involved in such a program, so this information is useful."

Payne said he was somewhat discouraged that the interquartile range of costs was so large and the average cost of $2800 seemed quite expensive, but he added that the economies of scale were encouraging. They show that the larger institutions can implement this program at a lower cost per patient.

"The model shows this approach is feasible, and I believe it to be a very important step in the right direction," he concluded.

The research was supported by the Agency for Healthcare Research and Quality. Trogdon, Bayliss, and Payne have disclosed no relevant financial relationships.

International Stroke Conference (ISC) 2020: Abstract LB8. Presented February 20, 2020.

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