Why It Matters
Age-Friendly care maximizes value for all involved: patients, caregivers, and the overall system. The following excerpt from IHI’s Business Case for Becoming an Age-Friendly Health System is a case study of the work at Hartford Hospital (Hartford, Connecticut, USA) to improve identification, prevention, and treatment of delirium. As a participant in the IHI Age-Friendly Health Systems Action Community, Hartford Hospital is implementing the 4Ms (What Matters, Medication, Mentation, and Mobility) to optimize care for older adults.
The business case for implementing the 4Ms in a hospital setting is predicated mainly on the health care costs avoided through the elimination of poor-quality care. Figure 1 shows the most common and costly adverse events that the 4Ms may potentially avert. In the figure, although each event is linked to one specific “M,” in practice all 4Ms work synergistically against each negative outcome.
Figure 1. Adverse Events Potentially Averted by Implementing the 4Ms
Consequently, the business case for the 4Ms should account for all the negative events they potentially avert, events predicted to occur under typical hospital care. To illustrate how health systems can construct the business case, the following case study focuses on a single adverse event: the incidence of delirium. However, the approach to making the business case for averting other adverse events with the 4Ms is identical. The business case for preventing delirium is based on lowering the hospital length of stay (LOS) and the daily cost. (The case would be even stronger were a hospital to bear some financial responsibility for its post-discharge or downstream sequelae: hospital-acquired delirium has been shown to increase nursing home placement and overall health care costs subsequent to hospital discharge.
This case study focuses on Hartford Hospital’s ADAPT (Actions for Delirium Assessment Prevention and Treatment) program. Hartford Hospital is a participant in the IHI Age-Friendly Health Systems Action Community. ADAPT has generated sufficient data to make a plausible business case for its age-friendly approach to care. Hartford Hospital, an 867-bed teaching facility, is part of Hartford HealthCare, a comprehensive health care network in Connecticut. ADAPT was introduced there in 2012 and is currently led by Christine M. Waszynski, DNP, APRN, GNP-BC, and Robert S. Dicks, MD, FACP. ADAPT is now being implemented in multiple hospital units where more than 4,000 patients were seen in 2018.
ADAPT Strategies
ADAPT’s delirium care pathway (see Appendix) is straightforward: screen all patients for delirium, prevent cases from developing, treat those that do, and manage cases that cannot be resolved. ADAPT is similar in most respects to the Hospital Elder Life Program (HELP), the widely studied and accepted standard of delirium care. ADAPT’s evidence-based strategies are firmly grounded in the “4Ms” Framework of an Age-Friendly Health System. In addition to Mentation, the main category into which delirium falls, the pathway explicitly includes the individualized plan of care (What Matters), mobilization and falls prevention (Mobility), and avoiding or stopping potentially inappropriate medications (Medication).
Prevalence of Delirium at Hartford Hospital
ADAPT screens almost all patients for delirium because the hospital’s data show that no age group or service line is immune to the condition. In 2018, diagnosed delirium varied between 5 percent to 50 percent in all hospitalized patients in the participating units. Delirium-positive rates vary by service, with coronary artery bypass grafting (CABG) being the highest, followed by trauma at slightly under 40 percent. Joint replacement had the lowest rate at about 5 percent. Current rates reflect implementation of ADAPT strategies, in the absence of which delirium rates presumably would have been higher.
Cost Avoidance with ADAPT Implementation
While the absence of data from a randomized control group makes it challenging to rigorously establish the ROI from ADAPT, the heavy financial burden that delirium imposes on this hospital, together with the low costs of ADAPT, sets up a plausibly strong business case for the efforts to prevent it.
Delirium cases are enormously expensive at Hartford Hospital. From July 2015 to June 2016, 35,700 hospital days were attributed to delirium, with hospital-incurred costs of about $96 million (post-acute care costs are not included). These delirium-related costs stem from an increased LOS combined with a higher cost per day, as shown in Table 3. Considering these two factors, delirium is responsible for adding more than $22,000 to a hospital stay. Hartford Hospital data and published studies support the position that delirium alone, rather than other factors, is responsible for the dramatic increase in hospital LOS.
The payer mix and payment systems under which Hartford Hospital operates ensure that the financial savings from ADAPT’s prevention efforts accrue to the larger Hartford HealthCare system. Older patients are primarily traditional Medicare beneficiaries, although a small number fall under per-diem or per-case rates paid by health plans with which the system contracts. Under fee-for-service, lowering length of stay creates a financial benefit.
Table 3. Hartford Hospital Per-Patient Costs Associated with Delirium
*Note: The cost of a stay with delirium is based on the extra cost per day applying just to the eight added days.
It can be misleading, however, to use the cost figure of roughly $22,000 (above in Table 3) as the financial return from preventing a case of delirium. The cost saving includes only the variable costs of that day, not the full costs, which include fixed elements that are unaffected by shorter stays. Thus, a conservative estimate, based on the assumption that fixed costs constitute 50 percent of the total, is that the financial benefit of an avoided delirium case is about $11,000. Demonstrating a positive ROI requires evidence that the cost of preventing a case is less than that amount. The cost of preventing a delirium case is a calculation that requires knowledge of 1) the costs of implementing ADAPT and 2) its effectiveness in reducing the incidence of delirium.
ADAPT requires minimal outlays: about $5 per patient for items (such as reader glasses, stuffed animals, personalized music, sleep eye masks) to improve function or provide comfort. There are, of course, indirect time-based costs for personnel. Additional time is required for ADAPT leadership tasks, for training (about two hours per nurse), for configuring the electronic health record, and for gathering and reporting data.
To date, Hartford Hospital has not attempted to convert these time requirements into a dollar equivalent. However, ADAPT’s leaders estimate that the total amount, including out-of-pocket and indirect costs, comes to no more than $50 per patient. (Note that this cost is considerably lower than the costs for HELP. In 1999, HELP was reported to cost $327 per patient, the equivalent of $630 in 2019 dollars. The cost disparity is due to two factors: first, ADAPT relies more heavily on volunteers; and second, unlike HELP, ADAPT does not have specific personnel whose only function is to oversee the program.)
While no concrete data have yet been reported on ADAPT’s effectiveness, it is highly likely that it is cost-beneficial. A financial tool called breakeven analysis, used in the context of data gaps, suggests this likelihood. With this tool, we calculated the percentage of delirium cases that ADAPT must prevent in order to be cost-neutral. Then, we compared this breakeven threshold to what might be reasonably expected.
If the breakeven threshold is a lower number of prevented cases than expected, it is plausible that the program will generate a positive financial return. When the analysis is performed even under the conservative assumptions, the breakeven threshold is minimal and likely to be far beneath what might be reasonably expected. The breakeven threshold is only 2 percent when the cost per patient is $100 and the value of a case prevented is $5,000. Research from HELP supports the view that up to 40 percent of delirium cases are preventable.
Summary
From the Hartford Hospital data and analysis applied to it, one might reasonably conclude that even under the most conservative scenarios, ADAPT should at least break even and probably perform far better than that. ADAPT, HELP, and other similar age-friendly initiatives to address delirium while also averting other iatrogenic events, such as falls, infections, and pressure sores, make a plausibly strong business case for their adoption. While the financial dimension is generally not the decisive factor for adopting the 4Ms, an attractive ROI should serve to encourage the scale-up and spread of age-friendly hospital care.