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Executive Summary

Medically complex patients tend to experience longer recovery journeys and are more likely to readmit to the ICU after hospitalization. For these patients, it is essential to reduce setbacks and readmissions. Learn about two care coordination strategies that can improve care efficiency and how Kindred Hospitals are taking them a step further.

As America’s hospitalized patients become increasingly complex, so does their treatment. Today, over 27% of American adults have two or more chronic conditions, and that percentage is expected to grow as the population ages1.  

When medically complex patients require hospital care, they tend to experience longer recovery times and are more likely to readmit to the ICU2. Contributors to total cost of care such as these can be mitigated by enhanced care coordination.

Read this white paper to learn about two care coordination strategies that are improving outcomes for medically complex patients and reducing cost of care.

Research into contributors to total cost of care

  1. Adverse events: A 2020 study from JAMA revealed a positive relationship between instance of adverse event rates and 30-day episode-of-care Medicare expenses for patients with serious conditions3.
  2. Avoidable days: Various articles have demonstrated that avoidable discharge delays are important contributors to total cost of care, and that limited capacity in the next level of care is a key cause of avoidable days4,5,6.
  3. Avoidable readmissions: A recent brief from the Agency for Healthcare Research and Quality (AHRQ) reported 3.8 million all-cause adult hospital readmissions, with an average readmission cost of $15,200 in 20187. With an estimated 27% of readmissions considered avoidable, this amounts to over $15 billion annually in avoidable readmissions8.

Internal coordination can reduce patient setbacks

One strategy for combatting patient setbacks is to break down clinical silos within a care setting and increase coordination across various departments.

Medically complex patients with multiple comorbidities often require a team of specialists who can address the different facets of their conditions. As more caregivers become involved in the patient’s treatment, there is an increased risk of miscommunication, which studies have found to be one of the primary causes of adverse and even sentinel events9.

When physicians, respiratory therapists, dieticians, bedside nurses, and others formally collaborate as an interdisciplinary care team to develop a comprehensive treatment plan, they are able to more efficiently and effectively treat their patients. This level of coordination has been shown to improve outcomes in ICUs10,11.

The benefit of interdisciplinary care team (ICT) collaboration is particularly clear when looking at patients requiring mechanical ventilation. One study found that when interdisciplinary teams of caregivers collaborated on long-term weaning plans, the result was a decrease in mortality and time on ventilator12.

When physicians and caregivers approach each patient’s treatment as a team, they can improve outcomes and decrease costly patient setbacks.

External coordination can improve access to appropriate level of care

Care coordination between the current provide and external health entities is another initiative that can support patient recovery and decrease costs.

The AHRQ defines this coordination as, "a patient- and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the health care system."13

Initiatives to improve external coordination can be implemented at various stages and levels of care. For medically complex patients that may require treatment after their initial hospital discharge, this can occur between post-acute care (PAC) providers and payers. When these entities collaborate to ensure patients receive the appropriate level of treatment for their clinical needs, they promote patient recovery and minimize costly discharge delays and readmissions.

Here are two examples of how care coordination programs can increase efficiency and care effectiveness.

Overcoming barriers to discharge

In some cases, patients may clinically be ready to discharge to a lower level of care, but are unable to do so because they require special accommodation or because the subsequent care setting does not have capacity. When providers from different levels of care and payers work together, they can remove these barriers and help advance the patient along the care continuum to the next, and typically lower-cost, setting.

Aligning medical necessity and the care setting

Medically complex patients may benefit from remaining in a more specialized care setting. If these patients do not receive the intensity of treatment they need from the outset, there is an increased likelihood of care disruptions and costly readmission further along the recovery. Clear communication between all entities leads to a more comprehensive understanding of the patients’ clinical needs and ensures that patients have access to the care they require, thereby reducing readmissions in the long run.

How Kindred Hospitals’ Programs are Bringing Caregivers and Partners Together

ICT Bedside Rounding

Kindred Hospitals’ interdisciplinary care teams of physicians, ICU/CCU-level nurses, respiratory therapists, and rehabilitation specialists collaborate to develop patient-specific care plans, helping to maximize potential for healing and minimize length of stay.

As part of their advanced care delivery model, Kindred’s interdisciplinary care goes above and beyond standard practice by including the patient and family in the team. The physicians and clinicians gather at the patient’s bedside daily to discuss patient and family goals, milestones, and progress, and to provide education and answer questions. This not only improves patient and family experience but also increases patient understanding and adherence to treatment plans which can further reduce avoidable readmissions.

Care Coordination Meetings

Kindred Hospitals also understand the importance of open communication with downstream providers and payers. As such, they have developed a program of care coordination meetings with payers that have many patients at Kindred.

During this time, medical directors and utilization management nurses can ask Kindred case managers specific questions about each of their patients in Kindred’s care, allowing them to get a more complete picture of the patient’s needs. Kindred can also discuss barriers to discharge and payers can provide network access where necessary to facilitate patient advancement.

In some cases, these discussions may lead to care conferences between Kindred, the payer, and the patient and family in which the entities can answer the family’s questions and guide the patient along the path to recovery. These care coordination efforts help ensure that patients receive the appropriate level of care, promoting recovery and mitigating risk of readmission.

Kindred Hospitals’ partner with health plans to provide the highest quality of care and help improve patient outcomes and lower costs for the sickest and most vulnerable patients. Kindred currently supports the following products:

  • Medicare Advantage
  • Commercial
  • Managed Medicaid
  • Veterans Affairs
  • Worker’s Compensation

Visit to request a conversation about how Kindred Hospital’s level of service can help manage your critically complex patients.


By Dr. Dean French, MD, CPPS