The Effect of Integrated Care After Discharge From Hospitals on Outcomes Among Korean Older Adults

Document Type : Original Article

Authors

Community Care Research Center, Health Insurance Research Institute, National Health Insurance Service, Gangwon, South Korea

Abstract

Background 
The Korean government implemented a pilot project for integrated care of older adults in June 2019. The pilot project of integrated care provided housekeeping support, nutrition support, movement assistance, home repair, consultations and education for healthy lifestyle, and some home-based primary care (HBPC) to older patients discharged from hospitals. This study investigated the outcomes of this project among older adults who participated in it after discharge from the hospital.
 
Methods 
This study combined the data from the pilot project survey with that from the National Health Insurance Service (NHIS). The participants comprised 1895 older adults who participated in the pilot project between August 1, 2019 and April 30, 2022. For comparison, 7145 older adults who lived in regions where no pilot project were selected as the matched group using propensity score matching (PSM). The length of home stay, total expenses of national health insurance (NHI) and long-term care insurance (LTCI), emergency visits, and hospital readmission for the same disease were measured, till July 31, 2022. Statistical analysis was performed through difference-in-differences (DID) analysis using a generalized estimating equation and the Cox proportional hazards model.
 
Results 
The results indicated an increase of 35.2 days (95% CI: 30.7, 39.8) in length of home stay over an average observation period of 550.5 days and a reduction of US$ 6960 (95% CI: -7,924, -5,996) in total expenses for participants compared to the controls. The odds ratio of emergency visits of the pilot project participants was 0.56 (95% CI 0.48, 0.65) compared with the controls. The hazard ratio (HR) for hospital readmission for the same disease after hospital discharge was 3.53 (95% CI: 2.98, 4.19) times higher in project participants than that in the controls.
 
Conclusion 
The pilot project for integrated care has resulted in an increased length of home stay and hospital readmission and reduced total expenses and emergency visits among older patients discharged from hospitals. The integrated care after discharge from hospitals can help older adults to continue living in the place where they lived, and improved collaboration between clinics and hospitals is required to prevent readmissions.

Keywords

References

  1. Kleinpell RM, Fletcher K, Jennings BM. Reducing functional decline in hospitalized elderly. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
  2. Szwamel K, Kurpas D. Indicators of an integrated home care model shaped by the needs of patients discharged from the emergency department. Int J Integr Care. 2020;20(4):16. doi:5334/ijic.5480
  3. Lattanzio F, Corsonello A, Montesanto A, et al. Disentangling the impact of chronic kidney disease, anemia, and mobility limitation on mortality in older patients discharged from hospital. J Gerontol A Biol Sci Med Sci. 2015;70(9):1120-1127. doi:1093/gerona/glv068
  4. Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689. doi:1001/jamasurg.2016.1689
  5. Liu L, Bopp MM, Roberson PK, Sullivan DH. Undernutrition and risk of mortality in elderly patients within 1 year of hospital discharge. J Gerontol A Biol Sci Med Sci. 2002;57(11):M741-M746. doi:1093/gerona/57.11.m741
  6. van Walraven C, Taljaard M, Bell CM, et al. A prospective cohort study found that provider and information continuity was low after patient discharge from hospital. J Clin Epidemiol. 2010;63(9):1000-1010. doi:1016/j.jclinepi.2010.01.023
  7. Verna EC, Landis C, Brown RS, et al. Factors associated with readmission in the United States following hospitalization with coronavirus disease 2019. Clin Infect Dis. 2022;74(10):1713-1721. doi:1093/cid/ciab464
  8. Liljas AEM, Brattström F, Burström B, Schön P, Agerholm J. Impact of integrated care on patient-related outcomes among older people - a systematic review. Int J Integr Care. 2019;19(3):6. doi:5334/ijic.4632
  9. Cho G. Suggestions for a data-based community care system in Korea. Ann Geriatr Med Res. 2020;24(4):313-315. doi:4235/agmr.20.0091
  10. Elderly Population Statistics. Korea Bureau of Statistics [Online]. Available at: https://www.kostat.go.kr/portal/korea/kor_nw/1/1/index.board?bmode=read&aSeq=420896. Accessed January 18, 2023.
  11. Campagna S, Conti A, Dimonte V, Berchialla P, Borraccino A, Gianino MM. Emergency department visits before, after and during integrated home care: a time series analyses in Italy. Int J Health Policy Manag. 2022;11(12):3012-3018. doi:34172/ijhpm.2022.6662
  12. Lubitz J, Cai L, Kramarow E, Lentzner H. Health, life expectancy, and health care spending among the elderly. N Engl J Med. 2003;349(11):1048-1055. doi:1056/NEJMsa020614
  13. Stall N, Nowaczynski M, Sinha SK. Systematic review of outcomes from home-based primary care programs for homebound older adults. J Am Geriatr Soc. 2014;62(12):2243-2251. doi:1111/jgs.13088
  14. Hammar T, Perälä ML, Rissanen P. The effects of integrated home care and discharge practice on functional ability and health-related quality of life: a cluster-randomised trial among home care patients. Int J Integr Care. 2007;7:e29. doi:5334/ijic.200
  15. Coffey A. Discharging older people from hospital to home: what do we know? Int J Older People Nurs. 2006;1(3):141-150. doi:1111/j.1748-3743.2006.00023.x
  16. Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care. 2005;17(2):141-146. doi:1093/intqhc/mzi016
  17. Parker SG, Peet SM, McPherson A, et al. A systematic review of discharge arrangements for older people. Health Technol Assess. 2002;6(4):1-183. doi:3310/hta6040
  18. Damery S, Flanagan S, Combes G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open. 2016;6(11):e011952. doi:1136/bmjopen-2016-011952
  19. Cheol Seong S, Kim YY, Khang YH, et al. Data resource profile: the national health information database of the National Health Insurance Service in South Korea. Int J Epidemiol. 2017;46(3):799-800. doi:1093/ije/dyw253
  20. Kane LT, Fang T, Galetta MS, et al. Propensity score matching: a statistical method. Clin Spine Surg. 2020;33(3):120-122. doi:1097/bsd.0000000000000932
  21. Silver ER, Truong HQ, Ostvar S, Hur C, Tatonetti NP. Association of neighborhood deprivation index with success in cancer care crowdfunding. JAMA Netw Open. 2020;3(12):e2026946. doi:1001/jamanetworkopen.2020.26946
  22. Choi JW, Yoo AJ. The impact of home-based primary care on outcomes among older adults in South Korea. J Am Med Dir Assoc. 2023;24(7):985-990.e2. doi:1016/j.jamda.2023.03.009
  23. Charlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP. The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. J Clin Epidemiol. 2008;61(12):1234-1240. doi:1016/j.jclinepi.2008.01.006
  24. Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med. 2009;28(25):3083-3107. doi:1002/sim.3697
  25. Normand ST, Landrum MB, Guadagnoli E, et al. Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores. J Clin Epidemiol. 2001;54(4):387-398. doi:1016/s0895-4356(00)00321-8
  26. Dimick JB, Ryan AM. Methods for evaluating changes in health care policy: the difference-in-differences approach. JAMA. 2014;312(22):2401-2402. doi:1001/jama.2014.16153
  27. Landi F, Gambassi G, Pola R, et al. Impact of integrated home care services on hospital use. J Am Geriatr Soc. 1999;47(12):1430-1434. doi:1111/j.1532-5415.1999.tb01562.x
  28. Landi F, Onder G, Russo A, et al. A new model of integrated home care for the elderly: impact on hospital use. J Clin Epidemiol. 2001;54(9):968-970. doi:1016/s0895-4356(01)00366-3
  29. de Stampa M, Vedel I, Buyck JF, et al. Impact on hospital admissions of an integrated primary care model for very frail elderly patients. Arch Gerontol Geriatr. 2014;58(3):350-355. doi:1016/j.archger.2014.01.005
  30. Hébert R, Raîche M, Dubois MF, Gueye NR, Dubuc N, Tousignant M. Impact of PRISMA, a coordination-type integrated service delivery system for frail older people in Quebec (Canada): a quasi-experimental study. J Gerontol B Psychol Sci Soc Sci. 2010;65B(1):107-118. doi:1093/geronb/gbp027
  31. Béland F, Bergman H, Lebel P, et al. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(4):367-373. doi:1093/gerona/61.4.367
  32. Tourigny A, Durand P, Bonin L, Hébert R, Rochette L. Quasi-experimental study of the effectiveness of an integrated service delivery network for the frail elderly. Can J Aging. 2004;23(3):231-246.
  33. Di Pollina L, Guessous I, Petoud V, et al. Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial. BMC Geriatr. 2017;17(1):53. doi:1186/s12877-017-0449-9
  34. Wieland D, Kinosian B, Stallard E, Boland R. Does Medicaid pay more to a program of all-inclusive care for the elderly (PACE) than for fee-for-service long-term care? J Gerontol A Biol Sci Med Sci. 2013;68(1):47-55. doi:1093/gerona/gls137
  35. Stokes J, Shah V, Goldzahl L, Kristensen SR, Sutton M. Does prevention-focused integration lead to the triple aim? An evaluation of two new care models in England. J Health Serv Res Policy. 2021;26(2):125-132. doi:1177/1355819620963500
  36. Béland F, Bergman H, Lebel P, et al. Integrated services for frail elders (SIPA): a trial of a model for Canada. Can J Aging. 2006;25(1):5-42.
  37. National Health Insurance Service. 2021 Long-Term Care Insurance Statistics [Online]. Available at: https://www.nhis.or.kr/nhis/together/wbhaec07200m01.do?mode=view&articleNo=10820535. Accessed January 18, 2023.
  38. National Health Insurance Service. 2021 National Health Insurance Statistics [Online]. Available at: https://www.hira.or.kr/bbsDummy.do?pgmid=HIRAA020041000100&brdScnBltNo=4&brdBltNo=10742. Accessed January 18, 2023.
  39. Doheny M, Agerholm J, Orsini N, Schön P, Burström B. Impact of integrated care on trends in the rate of emergency department visits among older persons in Stockholm County: an interrupted time series analysis. BMJ Open. 2020;10(6):e036182. doi:1136/bmjopen-2019-036182
  40. Mann J, Thompson F, McDermott R, Esterman A, Strivens E. Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial. BMC Health Serv Res. 2021;21(1):701. doi:1186/s12913-021-06668-x
  41. Campagna S, Conti A, Dimonte V, Berchialla P, Borraccino A, Gianino MM. Emergency department visits before, after and during integrated home care: a time series analyses in Italy. Int J Health Policy Manag. 2022;11(12):3012-3018. doi:34172/ijhpm.2022.6662
  42. Ruiz S, Snyder LP, Rotondo C, Cross-Barnet C, Colligan EM, Giuriceo K. Innovative home visit models associated with reductions in costs, hospitalizations, and emergency department use. Health Aff (Millwood). 2017;36(3):425-432. doi:1377/hlthaff.2016.1305
  43. Barbadoro P, Di Tondo E, Menditto VG, et al. Emergency department non-urgent visits and hospital readmissions are associated with different socio-economic variables in Italy. PLoS One. 2015;10(6):e0127823. doi:1371/journal.pone.0127823
  44. Sempé L, Billings J, Lloyd-Sherlock P. Multidisciplinary interventions for reducing the avoidable displacement from home of frail older people: a systematic review. BMJ Open. 2019;9(11):e030687. doi:1136/bmjopen-2019-030687

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History

  • Receive Date: 01 March 2023
  • Revise Date: 06 November 2023
  • Accept Date: 31 December 2023
  • First Publish Date: 02 January 2024

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