The “post-hospital syndrome” has been used to describe the vulnerable period after older patients are discharged from the hospital. The basic hypothesis is that in-hospital factors such as sleep deprivation, poor nutrition, immobility, medication changes, and complex instructions all make patients at-risk for adverse events such as hospital readmission. In practice, most of us have seen this phenomenon in our older patients at one point or another.
Intuitively, being good at coordinating care for older adults after they are discharged should lead to both better outcomes and cost savings. The health system can be incredibly challenging for older patients to navigate. Care coordination can include activities such as ensuring a patient has timely access to an outpatient visit after hospital discharge; evaluating whether they have their needed medications; and facilitating that primary care and specialist care plans are aligned. All of these have the potential to prevent adverse events for patients (e.g. missing a dose of needed medication) and therefore plausibly lead to cost savings through reducing harmful events.
I was therefore intrigued by a recent editorial in the New England Journal of Medicine that called into question exactly how much cost savings care coordination achieves. The author points out that care coordination itself costs money; both in terms of personnel (care coordinators) and information health technology. Moreover, a large number of patients may need to have their care properly “coordinated” in order to measurably prevent a single adverse event. The article goes on to highlight that care coordination is politically more palatable than other approaches to cost reduction, such as restricting access or rationing. This likely explains the broad enthusiasm for it, even if is not necessarily the most cost effective option.
Is care coordination still the appropriate thing to do? I think so. I have had several particularly complex older patients where a dedicated care coordinator made the difference between a good outcome (e.g. reducing redundant medications, making sure that all specialists were on the same page) and a bad one. But perhaps we need to weigh care coordination on merits other than cost – such as how it can improve patients’ experience with the health system – in order to ensure its long-term viability.
By: John Dodson, MD