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The Adoption and Spread of Hospital Care Coordination Activities Under Value-Based Programs
Larry R. Hearld, PhD; Nathaniel Carroll, PhD; and Allyson Hall, PhD
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The Adoption and Spread of Hospital Care Coordination Activities Under Value-Based Programs

Larry R. Hearld, PhD; Nathaniel Carroll, PhD; and Allyson Hall, PhD
Value-based programs such as accountable care organizations appear to encourage the adoption and spread of care coordination activities by hospitals.
ABSTRACT

Objectives: To examine the relationship between participation in value-based programs and care coordination activities.

Study Design: Cross-sectional, observational study of 1648 US hospitals using the American Hospital Association (AHA)’s 2013 Survey of Care Systems. Value-based program participation included participation in either an accountable care organization (ACO) or a bundled payment program. We assessed adoption (whether a hospital was using any of a set of 12 care coordination activities in the AHA survey) and spread (in each hospital adopting care coordination activities, how extensively those activities were implemented throughout the hospital).

Methods: Ordinary least squares regression assessed associations between participation in an ACO or bundled payment program and the adoption and spread of 12 care coordination activities.

Results: Hospitals adopted nearly two-thirds of the possible care coordination activities (mean [SD] = 7.9 [4.4] of 12). Among those hospitals adopting care coordination activities, there was a relatively moderate spread of these activities (mean = 2.5; range, 1 [minimally used] to 4 [used hospitalwide]). Hospital participation in an ACO was associated with the adoption of 3.07 more care coordination activities (P <.001), on average, and 0.16 more points on the scale of spread of care coordination activities (P <.001) compared with hospitals that were not participating in an ACO. Hospital participation in a bundled payment program was associated with the adoption of 1.84 more care coordination activities (b = 1.84; P <.001) but not greater spread (b = –0.04; P = .54).

Conclusions: Value-based programs such as ACOs appear to encourage the adoption and spread of care coordination activities by hospitals.

Am J Manag Care. 2019;25(8):397-404
Takeaway Points
  • Overall, US hospitals adopted a relatively high number of care coordination activities (nearly two-thirds, on average, of those possible) but were less interested in or effective at spreading these activities throughout the hospital.
  • Opportunities to improve the use of care coordination activities are not evenly distributed, with hospitals reporting extensive use of some activities and minimal use of others.
  • Hospital participation in value-based programs, especially accountable care organizations, may provide a catalyst to adopt and spread care coordination activities.
Care coordination—defined as the deliberate organization of patient care activities between 2 or more participants (including the patient) involved in a patient’s care to facilitate appropriate delivery of healthcare services1—is an essential component of high-quality, high-value care. For example, research has found that care coordination activities that help patients transition out of the hospital and back into the community are effective at avoiding undesirable outcomes, such as unnecessary readmissions.2-4 However, research has also documented varying degrees of care coordination capabilities among providers,5 highlighting an important opportunity for improving the quality of care.

Considerable emphasis in recent years has been placed on incentive programs such as accountable care organizations (ACOs) and bundled payments in the hopes that they will improve the value of healthcare in the United States. One means by which these programs may do so is by improving care coordination activities by healthcare providers, including and especially hospitals.6-10 Research is beginning to emerge as to whether these programs are effective at promoting quality and lowering costs11-15; however, related but underresearched questions pertain to whether these programs are effective at promoting care coordination activities.16 Answers to such questions are important for understanding reasons these programs may or may not be effective at promoting value in the US healthcare system.

Therefore, the purpose of this paper was to examine the adoption and spread of care coordination activities among US hospitals following the introduction of value-based payment programs. Further, the paper assesses the degree to which the adoption and spread of care coordination activities varies as a function of participation in these programs.

STUDY DATA AND METHODS

Data Sources

Bundled payment and Medicare ACO programs were launched by CMS in 2012.17 We focused on 2013 to understand how well prepared early adopters of these programs were to coordinate care. Therefore, we consider our findings important in providing a baseline assessment of how hospitals may have responded to the incentives that these programs offer.

The data for this study were drawn from 3 sources: (1) the 2013 American Hospital Association (AHA) Annual Survey of Hospitals, (2) the 2013 AHA Survey of Care Systems, and (3) the Health Resources and Services Administration’s 2013 Area Health Resource File (AHRF). The AHA Annual Survey of Hospitals is an annual electronic survey of approximately 6300 hospitals in the United States that provides extensive data regarding hospital organizational characteristics.18 The AHA reports an 80% response rate to this survey each year. The Survey of Care Systems is a relatively new data collection effort by AHA, initiated in 2013, to monitor the evolution of new systems of care such as ACOs. The 2013 survey used in this analysis included 1648 hospitals, or approximately 34.4% of the general service acute care hospitals in the United States. The AHRF is a collection of data from different sources (eg, US Census Bureau, Bureau of Labor Statistics) that is used to construct the environmental characteristics considered in the study. The final analytic sample consisted of 1648 US acute care hospitals operating in 2013.

Dependent Variables

The analysis included 2 dependent variables related to hospital-initiated care coordination: adoption and spread. Adoption refers to the decision to use a new technology or process, whereas spread (also known as penetration or reach) pertains to the integration of that new technology or process within a setting.19,20 In our study, the adoption of care coordination activities reflected how many different care coordination activities were reported as being used by a hospital. The AHA survey included questions that asked hospitals about whether they were engaging in 12 care coordination activities (Table 1). The use of each activity was measured on a 5-point scale (“not at all used,” “used minimally,” “used moderately,” “used widely,” or “used hospitalwide”). To construct our care coordination adoption variable, we first constructed a dichotomous indicator (“used” or “did not use”) for each care coordination activity (0 if hospitals reported these activities were not at all used and 1 if hospitals reported they used these activities minimally, moderately, widely, or hospitalwide). Next, we summed these dichotomous indicators for each hospital (range, 0-12), with greater values indicating greater adoption of care coordination activities. As a sensitivity analysis, we estimated these relationships using a more conservative estimate of adoption (0 if hospitals reported not using these activities at all or using them minimally and 1 if hospitals reported using these activities moderately, widely, or hospitalwide). The results using this definition of adoption were similar to those reported here (results available from authors upon request).


 
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