From Acute Care to Home Care: The Evolution of Hospital Responsibility and Rationale for Increased Vertical Integration

EXECUTIVE SUMMARY The responsibility of hospitals is changing. Those activities that were once confined within the walls of the medical facility have largely shifted outside them, yet the requirements for hospitals have only grown in scope. With the passage of the Patient Protection and Affordable Care Act (ACA) and the development of accountable care organizations, financial incentives are focused on care coordination, and a hospital's responsibility now includes postdischarge outcomes. As a result, hospitals need to adjust their business model to accommodate their increased need to impact post-acute care settings. A home care service line can fulfill this role for hospitals, serving as an effective conduit to the postdischarge realm--serving as both a potential profit center and a risk mitigation offering. An alliance between home care agencies and hospitals can help improve clinical outcomes, provide the necessary care for communities, and establish a potentially profitable product line. INTRODUCTION For years, the issue of patient handoffs has plagued hospitals. A search of the literature highlights many issues regarding the difficulty involved in ensuring high-quality care for patients when transitioning between providers. Forster, Murff, Peterson, Gandhi, & Bates (2003) found that one in five patients experiences an adverse event (defined as an injury resulting from medical management rather than from the underlying disease) in the transition from hospital to home. They also found that approximately 62% of adverse events could be either prevented or ameliorated. A 2008 Commonwealth Fund study found that among eight industrialized nations, the United States had the highest rate of readmissions within 2 years to the hospital or patients visiting an emergency department (ED) as a result of complications that arose during recovery (Table 1). Despite all the data reporting high postdischarge readmission rates, hospital discharge procedures have not been standardized (Greenwald, Denham, & Jack, 2007). This lack of consistency represents a large problem because systems to ensure that patient data are transferred to subsequent caregivers in an efficient and effective manner are inappropriate or ineffective (Moore, Wisnivesky, Williams, & McGinn, 2003; Wachter, 2004). For example, discharge summaries frequently lack critical data and are not sent to the patient's primary care physician in a timely fashion (Kripalani et al., 2007; Van Walraven, Seth, Austing, & Laupacis, 2002). Roy et al. (2005) examined test results pending at the time of discharge and determined that posthospital providers were frequently unaware that results were pending, posing a potentially serious clinical threat. Specifically, delays in the reporting of test results are responsible for incomplete patient evaluations (Moore, McGinn, & Halm, 2007; Roy et al, 2005). Furthermore, a meta-analysis revealed that only 12-34% of discharge summaries had reached aftercare providers by the time of the patient's first post-hospitalization appointment (Kripalani et al, 2007). In addition, patients were often left unprepared at discharge--many of those questioned did not understand their discharge medications and could not recall their chief diagnoses (Makaryus & Friedman, 2005). A poor transition often leads to a poor understanding--on the part of both the patient and the caregivers--of health status, which can result in negative consequences for the patient, including the following (Williams, Davis, Parker, & Weiss, 2002): * Difficulties navigating the healthcare system * Nonadherence to prescription medications and dosages * Missed physician appointments With more than 32 million adult discharges in the United States each year (Levit et al., 2007), these deficiencies in the transition of care can increase the rates of illness among them, lead to unnecessary hospital utilization, and incur unnecessarily high costs of care. …