Comparison of Care and Cost Outcomes for Stroke Patients With and Without Home Care

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1 Comparison of Care and Cost Outcomes for Stroke Patients With and Without Home Care BY NANCY H. BRYANT, R.N., B.S.,* LOUISE CANDLAND, R.N., M.A.,t AND REGINA LOEWENSTEIN, A.M Abstract: Comparison of Care and Cost Outcomes for Stroke Patients With and Without Home Care This study was undertaken to compare care and cost outcomes of stroke patients who received home care with those who did not receive home care at St. Luke's Hospital Medical Center, New York, New York. Twenty-five home care stroke patients were matched by age and sex with comparable stroke patients receiving no home care during 9. After nine months' follow-up, stroke patients who received home care had shorter hospital stays (average, ten days less), overall costs greatly reduced (average, $, for home care patients versus $, for comparison group), fewer readmissions for recurring strokes, and fewer deaths (two versus nine). At the end of nine months, home care patients were located as follows: at home, two on home care, one in a nursing home, and two were dead. The comparison group showed: eight at home, one at an extended-care facility, seven in nursing homes, and nine were dead. The differences in care and cost outcomes between these two groups have considerable implications for patients, hospitals, physicians, and third party payers. Additional Key Words extended-care facility hospital stay nursing home D This study was undertaken to compare care and cost outcomes of stroke patients who received home care with those who did not, as a method of evaluating the Home Care Department of St. Luke's Hospital Center, New York, New York. It was felt that selecting a matched group of patients with a similar diagnosis and comparing those patients who received home care services and those who did not for a ninemonth period would be helpful in making this evaluation. Numerous studies have been made on home care programs for the purposes of evaluating care received, number of days saved from the hospital stay, and needs of specific age groups in the population for this service. of the studies, however, have tried to compare patient costs over an extended period of time, as well as outcome of services, for patients with a similar diagnosis. One of the most comprehensive studies of home health agencies (Home Health Services Study, New York City Metropolitan Area: 9 to 9) was done by van Dyke and Brown. They examined the actual *M.P.H., January, 9, Columbia University School of Public Health, New York, New York. thome Care Administrator, St. Luke's Hospital Center, New York, New York. ^Assistant Professor of Administrative Medicine, School of Public Health, and Leader, Statistical Area, Center for Community Health Systems, Columbia University, New York, New York. services delivered to patients in nine counties in the New York City area by various types of home health agencies. By showing the problems encountered as well as the needs of the population, they hope to influence government, health planners, third party payers, etc., in "developing home care as an integral part of the pattern of health services delivery in the future." Home Health Services in the United States, A Report to the Special Committee on Aging presents a complete review of home health agencies, the population in need, the types of services available, the potential of the services, the limitations of the systems for providing the services, the various types of home care programs and their relationship to other institutions. It describes in detail the basic components of home health services and the potential of these services in health maintenance organizations and ambulatory care facilities. Cost saving and manpower also are dealt with. The conclusions and recommendations forcefully endorse increased home health services and more adequate funding of these services. Testimony by experts and laymen are included in the report. Rawlinson's report deals with Blue Cross involvement in home care programs in the Greater Philadelphia area. She describes the development of the programs and the reimbursement plan. Also included is information similar to that covered in this Stroke, Vol., January-February 9

2 CARE AND COST OUTCOMES FOR STROKE study about patients in nine different hospitals. The report concludes "that % of all hospitalized patients could be transferred to coordinated home care earlier in their illness with a corresponding reduction in the use of inpatient facilities." The physicians interviewed were generally in favor of the service. The study by Morris and Harris on home health services in Massachusetts first gives the background of home health agencies in the United States, noting that only.% of Medicare money in 9 was spent on this service. "The inquiry in Massachusetts sought to identify the extent to which home health services are in fact provided to consumers, the cost of delivering such services in at least rough form, and the projected costs of delivering such services to the entire population at risk." Messier points out that third party payers are still not convinced of the cost savings in home care programs. This has resulted in delays in payments and changes of eligibility for reimbursement which have made many New York hospitals wary of continuing this service. The result is that home care programs are operating at minimum effectiveness and the patients are the ones who suffer. Methods The study group consisted of stroke patients admitted to the Home Care Department of St. Luke's in 9. The requirements for admission to home care are: () the physician has requested care at home, () the physician has made a plan of care, and () the patient is medically ready for transfer from hospital to home. In addition, the patient must require one or more of the following home health services: skilled nursing care, physical therapy, social service, occupational therapy, inhalation therapy, or speech therapy. Records were readily available from the Home Care Department as were hospital records of these same patients. Twenty-five home care patients fulfilled the requirements of primary diagnosis of stroke in 9. The selection of 9 admissions allowed for a nine-month follow-up. It also was felt that nine months permitted sufficient time for resolution of the stroke or for recurrence and worsening of the condition. Comparison patients were selected from two sources: those patients admitted to St. Luke's Hospital with a primary diagnosis of stroke who did not receive home care but did receive physical therapy in the hospital (referred to as the group), and those patients admitted to the hospital with a primary diagnosis of stroke who received no home TABLE Age and Sex of Home Care Patients Age Male Female & over 9 TABLE Number of Days in Hospital From Admission to Discharge for Home Care () and Patients Days days. _.9 care and no physical therapy (referred to as the Neither group). Both groups were matched by age and sex with the home care patients. The two different groups were used in order to compare their hospitalization and after care course with the home care patients. Characteristics compared for all three groups were: number of days in the hospital, services provided in the hospital, hospital discharge destination, readmissions to the hospital (if any) and reason for readmission, length of stay, and subsequent discharge destination. Further information was included for home care patients: number of days on home care, services provided by home care, discharge destination, and costs. Further information also was included for the and Neither groups: number of days in extended-care facilities (ECF),* discharge destination, and the number of days in nursing homes. Finding the appropriate time to start computing costs for stroke patients is very difficult when one considers the great range of severity possible in such an illness. This is especially true if the patient is also suffering from other diseases at the same time. Therefore, costs were computed from the day the patient went to the Physical Therapy Department (or was discharged) and for the next nine months. The neurologist consulted on this matter believed that the patient's physician would not order the patient to the Physical Therapy Department before the patient was stabilized medically. Although this criterion proved to be the most workable and accurate of others that were considered, it did present some problems. *Since January, 9, ECF (extended-care facilities) are now called Skilled Nursing Facilities. TABLE Number of Days in Hospital From Admission to Start of Physical Therapy for Home Care and Patients Day« days. _L. Stroke, Vol., January-February 9

3 BRYANT, CANDLAND, LOEWENSTEIN First, it meant that the Neither group could not be included in all comparisons, especially costs. Second, some patients first started receiving physical therapy at the bedside because they were unable to go to the Physical Therapy Department. They subsequently had all physical therapy in their rooms, although they were medically able to go to the Physical Therapy Department. This situation required detailed examination of the patient's chart to determine when the patient was receiving physical therapy out of bed in his room and therefore was able to go to the Physical Therapy Department. Third, a few patients never received physical therapy out of bed. In this case, costs were first computed on the day of discharge, when the patient was stabilized medically for a move to home or an ECF. Hospital costs were calculated from the Medicare reimbursement rate to St. Luke's Hospital at $ per patient per day. Other Medicare reimbursement rates used were $9 per day at chronic care facilities, $ per day for rehabilitative institutes, and $ per day in nursing homes. Costs for patients in St. Luke's Home Care Program include the Department's per diem rate of $. plus actual costs for services rendered, such as visits by the visiting nurse, physical and occupational therapists, home health aides, social service workers, laboratory tests and equipment. Not included are the costs related to maintaining a home paid by patients, welfare or voluntary agencies and costs of visits the patients made to clinics or their private physicians. As the study progressed, the records revealed that the Neither group was composed of patients at either extreme of medical severity. A large proportion of them had mild strokes, required only a short hospitalization and used few of the hospital services, such as physical therapy, occupational therapy, speech therapy, etc. On the other hand, patients from the Neither group had severe strokes and died in the hospital. Since this group was not comparable with the home care and groups, data concerning it are not included in the findings. The home care and patients are comparable insofar as possible: they were matched by age and sex, the extreme cases of stroke (both mild and severe) were eliminated, all patients were alive at discharge, and medical stabilization (as previously described) had taken place before hospital days and costs were counted. Findings and Discussion The sex and age distributions of the stroke patients followed by the Home Care Department fit the TABLE Number of Days From Start of Physical Therapy to Discharge for Home Care and Patients Days days.. TABLE S Number of Days in Hospital by Age for Home Care and Patients Under years years and over Number of patients Number of days in hospital 9 days in hospital.... general pattern for this disease (table ). Twenty-three patients are age and over, and although divided equally between the sexes, the females constitute the greatest number of the years of age and over group. This agrees with van Dyke and Brown's findings that most home care patients were years old and over. patients were matched by age and sex with this group. The number of days in the hospital from admission to discharge for both groups is shown in table. Home care patients spent an average of days per patient in the hospital and patients averaged almost days per patient. Table shows that from admission to the start of physical therapy, the home care and patients averaged almost the same number of days,. and. respectively. When counting from the start of physical therapy (as described earlier) until hospital discharge, table reveals that home care patients averaged. days per patient while the patients averaged. days per patient. For comparing the number of days in the hospital and hospital costs for both groups, the counting of hospitalization days began on the day the patient went to the Physical Therapy Department. This meant that all patients were at a similar degree of medical stability. For those patients who did not reach this medical stability until discharge, then the counting of days began at discharge. This method was used to avoid skewing the figures in favor of one group or another by a few patients who had prolonged hospitalization because of severity of illness. No other attempts at determining the severity of illness were made, since it TABLE Use of Services in the Hospital by Age and Group Under years years A aver Number of patients Services: Physical therapy Occupational therapy Intensive care unit Speech therapy Social service Inhalation therapy Stroke, Vol., January-February 9

4 CARE AND COST OUTCOMES FOR STROKE TABLE Number of Days on Home Care fay Age Under years years A aver Number of patients Number of days on home care days on home care,.,. 9. was not in the scope of the study to do so. Examination of tables through reveals that although the patients averaged almost days more per patient in the hospital than the home care patients, ten of these extra days occurred after physical therapy began. Another way to examine number of days in the hospital is to divide the patients into two groups: () under years of age, and () years of age and LOCATION OF BY PLACE IN THE MONTHS FOLLOWING DISCHARGE OR START OF PHYSICAL THERAPY HOME CARE HOSPITAL PHYSICAL THERAPY I I 9 I Z ' e A 9 9 MONTHS HOME Figure l a (top) MONTHS LOCATION OF BY PLACE IN THE MONTHS FOLLOWING DISCHARGE OR START OF PHYSICAL THERAPY HOME CARE PHYSICAL THERAPY EXTENDED CARE FACILITY I 9 9 ol I l I I I I l l I 9 9 over. The average number of hospital days per patient under years of age and years of age and over is and, respectively, while for the home care group the days are and, respectively (table ). One would assume that, as is the case with home care patients, those years and over, because of age and complications, would have a longer hospitalization. But this is not the case for the patients, where both age groups spent about the same amount of time in the hospital. The implication is that home care patients are discharged sooner after stabilization than patients. The reasons for this could be several: that the Home Care Program can provide the necessary services at home and the physician is willing to discharge the patient sooner, that the patient has an adequate home to go to, and that the patient's family or a home health aide is available to help care for the patient at home if needed. Rawlinson reported that physicians who used Home Care Programs estimated that the average hospital stay of the patient was reduced by days. This corresponded with our findings of at least ten days saved by home care. It would seem that in the case of stroke patients, ON HOME CARE BY MONTH FROM DISCHARGE co. g. u., HOME CARE b z Mil 9 MONTHS Figure Ib Stroke, Vol., January-February 9

5 BRYANT, CANDLAND, LOEWENSTEIN TABLE Costs for Nine Months From the Start of Physical Therapy or Hospital Discharge for Home Care and Patients Costs < $999 $,-,9,-,999,-,999,-,999,-,99,- 9,999,-,999,-9,999,-9,999 Median $,. $,. $,. $,. the Home Care Department is meeting its objectives of shortening the hospital stay and promoting "the best utilization of existing hospital facilities by releasing hospital beds for those who need acute care." Use of hospital services was compared also by age and group (table ). The services used most frequently were physical therapy and social service in all age group categories. Occupational therapy, the intensive care unit, speech therapy and inhalation therapy were infrequently used in comparison. There was a somewhat greater use of services such as physical therapy, occupational therapy and social service in the years old and over patients. As might be expected, home care patients years of age and over stayed in the Home Care Program somewhat longer than the under years of age group 9. to. days, respectively (table ). This probably reflects the longer time needed for the older patients to recover enough to be discharged to themselves and/or their families. Hospital readmissions were few in number for both groups. One home care patient and two patients were readmitted because of another stroke or worsening of their original condition. Three home care patients and three patients were readmitted for other conditions unrelated to their strokes. TABLE 9 Summary of Costs per Patient for Nine Months From Start of Physical Therapy or Hospital Discharge Type of cost Physical therapy to hospital discharge Hospital readmission for stroke Home care Skilled nursing facility Nursing homes mean Number of patients $, 9 9 $,9 () $,9,,9 $, () After the nine-month follow-up an overview of all patients by month and location is shown in figure la and b. Starting with the first month after physical therapy was started in the hospital (or with discharge), the location of patients of each group is shown for each of nine months. Over the nine-month period there was a steady increase in the number of patients living at home in the home care group. Of the patients, were living at home by the end of the nine months and two of the patients were still being carried on home care. Only one home care patient was in a nursing home and two had died. On the other hand, eight patients were at home, one was in an ECF, seven were in nursing homes and nine had died. costs for the nine-month period included costs of: St. Luke's hospitalization from physical therapy to discharge, number of days on home care plus services, number of days in an ECF, number of days in nursing homes, and number of days in the hospital on readmission if for another stroke or worsening of the original condition. It was assumed that patients who were admitted to nursing homes remained there indefinitely, since there were no contraindications to this assumption. Not included in these costs were hospitalization for conditions other than stroke or costs other than home care while at home. Tables and 9 give the overall amounts for the two groups for nine months from the start of physical therapy or hospital discharge. Table shows the number of patients in each cost category and table 9 summarizes the mean costs per patient by facility. The mean cost per home care patient was about $,, while the cost per patient was about $,. The median costs show somewhat lower figures for home care patients ($,) and for patients ($,). In either instance, the difference ($, or $,) is considerable and deserves closer examination. Table shows almost equal mean costs of hospitalization for both groups of patients before physical therapy was started. These costs, presumably, are not reducible since they occurred before the patients were TABLE Hospital Costs From Admission to Physical Therapy Home Care and Patients Costs $ ,-,999,-,999,-,999,-,999, & over $,9 for $,9 Stroke, Vo/., January-February 9

6 CARE AND COST OUTCOMES FOR STROKE TABLE TABLE Hospital Costs From Physical Therapy to Discharge for Home Care and Patients Co»t» $ ,-,999,-,999,-,999,-,999, & over $, $,9 stabilized and when hospitalization was considered essential. Table shows the hospitalization costs after stabilization while the patients were receiving physical therapy. It is during this period that the home care patients are discharged an average of ten days earlier TABLE Costs for Patients on Home Core Costs $ ,-,999,-,999 mean per day per patient TABLE per diem $ $ Ex/ended-Care Facilities(ECF) Costs for and Patients Colts $ ,-,999,-,999,-,999,-,999,-,99,- 9,999,-,999,-9,,-9, per patient per patient using facility $9 $,9 services 9 $9 $. Home Core $, $, Nursing Home Costs for Home Care and Patients Costs < $,,-,999,-,999,-,999 9,-9,999 per patient per patient using facility $ $, $,9 $, than the patients (table ). At the hospital per diem rate of $, the savings to the patient, Blue Cross, Medicare, etc., are considerable. The savings can be compared with the alternate cost of carrying these patients on home care, which is $. per patient per day (table ). Since patients were not discharged to home care, they continued to have increased costs in ECF and nursing homes (tables and ). During the nine-month period only three home care patients required these facilities while 9 patients used ECF and/or nursing homes. Comparison of costs of ECF at $ and $9 per day and nursing homes at $ per day with the average costs for stroke patients in the Home Care Program at $. per day indicates that every effort should be made to make use of home care services. Conclusions When compared with comparable stroke patients in the same hospital, the home care patients had: () a shorter hospitalization, () fewer readmissions for recurring stroke, () received continuity of care for as long as needed, () their overall costs greatly reduced, () fewer deaths, and () the ability to be discharged to themselves or family and remain self-sufficient in the community. References. van Dyke F, Brown V: Organized home care: An alternative to institutions. Inquiry 9: - (June) 9. Rawlinson H: Coordinated Home Care: An Effective Alternative. Excerpts from report by Blue Cross of Greater Philadelphia, Home Health Services in the United States, A Report to the Special Committee on Aging, appendix, p, 9. Home Health Services in the United States, A Report to the Special Committee on Aging. U.S. Senate, U.S. Government Printing Office, Washington, D.C., 9. Morris R, Harris E: Home health services in Massachusetts, 9: Their role in care of the long-term sick. Amer J Public Health : - 9 (Aug) 9. Messier EA: Reimbursement for home health agencies. (Presented at the 9 Mid-Atlantic Health Congress). Policy Manual. St. Luke's Hospital Center Home Care Department, St. Luke's Hospital Center, New York, New York Stroke, Vol., January-February J9 9

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