Practicality of Acute and Transitional Care and its consequences in the era of SwissDRG: a focus group study

Enabling careful transition of patients from acute care hospitals to other care settings is important to ensure continuity of care, reduce re-hospitalization [1‐3], and save costs [4]. Transitional or intermediate care ensures that patients receive necessary support at another setting, such as specialized nursing homes, rehabilitation centers, hospitals with intermediate care facilities, or at home with ambulatory nursing care [4‐6]. Naylor and colleagues [7] identified key components of comprehensive transitional care, which include educating and engaging patients as well as caregivers, addressing their well-being needs, appropriately managing medications and complex health needs, ensuring care continuity, and accountability. Several studies evaluating transitional care interventions highlight their positive outcomes, such as reduced readmission and decreased mortality [4, 8‐11].

In Switzerland, the Federal Law on Health Insurance (Bundesgesetz über die Krankenversicherung (KVG)) introduced Acute and Transitional Care (ATC) with a special financing option in 2011 (Art. 25a para 2, KVG, SR 832.10). The goal was to support those patients who, after acute treatment at a hospital, require increased professional care for a limited amount of time. ATC aims to allow patients to restore to the health status they had before hospitalization and facilitate their return home. According to Art. 25a (para 2) of the Federal Law on Health Insurance, a number of requirements must be fulfilled for the canton (i.e. federal state) and health insurance to participate in its financing [12, 13]. Specifically, there must be a necessity of using this discharge option, it should follow hospital stay, and a hospital doctor should prescribe it. Differently from rehabilitation after hospitalisation, prior cost-approval by health insurance is not required for ATC [12, 14, 15]. According to the law, different care providers can offer ATC, namely nursing care professionals, home care services, and nursing homes. The first two offer an ambulatory variant of ATC, whilst nursing homes provide stationary ATC. This difference has cost-related consequences for patients because the stationary variant comes with room and board costs [12].

ATC is meant to be financed on a dual-fix basis by the canton and the insurer. That is, the canton pays at least 55% of the cost and the insurer 45%. However, according to the law, it is unclear which costs are to be reimbursed and by whom [16]. Thus, the reimbursement is implemented variably in the different cantons. As a rule, the cost of care is reimbursed, while the remaining cost associated with nursing home room and board are paid by the patient [12].

ATC aims to support patients who may be released early from the hospital because of the implementation of Swiss Diagnosis Related Group (SwissDRG). At an international level, DRG is associated with earlier discharge of patients, thus raising concerns related to poorer patient outcomes [17], but such alleged negative side-effects of DRGs are yet to be substantiated in Switzerland [18‐22]. A worldwide systematic review of DRG outcomes [23] and a scoping review examining DRG in Switzerland and Germany [24] underlined that neither positive nor negative conclusions could be drawn from available data in light of its heterogeneity. However, it is widely believed that DRGs result in worse quality of care for vulnerable patient groups [15, 25]. It is thus crucial that ATC is implemented appropriately at a practical level, so that potential negative outcomes of DRGs are mitigated. Interviews with hospital experts in Switzerland revealed that there is scepticism concerning the usefulness of ATC [26]. Furthermore, it is feared that certain groups of vulnerable patients - in particular older persons, children, and those who lack language competency – are likely to be discriminated in a framework where the hospital payment system is based on DRGs [13, 27].

Because ATC is a relatively new discharge option, we know little about its implementation and actual use. As part of a nationally funded project on ATC, we gathered both quantitative and qualitative data to understand this discharge option. Our first findings from the quantitative part of the project revealed that more problems occurred with patients who were discharged to ATC when compared to other groups (including rehabilitation), and that female patients were more likely to receive ATC as a discharge option in comparison with rehabilitation [28]. In another paper, we explored medical records of patients and found that older patients lacking private insurance (supplementary to mandatory basic health insurance) and having smaller social networks were more likely to receive ATC than rehabilitation [29]. Therefore, our previous results reveal that vulnerable patient groups (i.e. older female patients and lacking private insurance) were discharged to ATC, an undesired option considering the additional nursing home costs. That certain vulnerable groups tend to receive ATC raises questions on detailed planning of hospital discharges. In light of the very limited empirical evidence on the practicality and the implementation of ATC, we used qualitative focus group methodology to explore professional stakeholders’ perspectives on the implementation of ATC.

Concerning the use of ATC, the following three themes were important that underpin ATC’s (lack of) practicality and its consequences for the nursing homes: (a) limited implementation of ATC including its differential implementation; (b) challenges with ATC as a discharge option and its reduced value in practice; and (c) the needs of complex patients that nursing homes offering ATC are unprepared to address (see Table 1 for themes and sub-themes).

This study presents important findings that confirm several concerns raised about ATC. According to the ATC regulation, this discharge option may be offered in two variants: ambulatory or stationary [12, 16]. Our data show that the standards of ATC differ geographically. Specifically, in the five cantons from which we gained information, it was clear that ATC was provided either in the stationary variant only (Italian-speaking) or in the ambulatory variant only (one German-speaking and the French-speaking canton). In two cantons (both German speaking), both variations are used, with a preference for stationary ATC. Although this variability seems to be a result of cantonal differences in applying the ATC regulation, this has consequences for the patient [31]. For example, it emerged that patients in German-speaking cantons where stationary ATC is used have to pay the total room and board costs, while those in the Italian-speaking canton pay only a portion of the room and board costs. Stationary ATC in many cantons is associated with out-of-pocket cost for the patient amounting to approximately CHF 180 per day, except for in one canton, where patients pay CHF 50 per day [31]. The financing of ATC remains sub-optimal [16] and from our interviews, it appears to not be uniform. The reason for this differential implementation of the law requires clarification.

Study participants noted that services provided through the ATC discharge option are not unique, since they do not differ substantially to what is already available outside the ATC framework [e.g. short-term stay at nursing home; nursing care service at home]. Thus, except for changes in the financing structure of nursing homes and home care service for the 14 days during which ATC order is given, there seems to be no qualitative difference in the care patients receive. Furthermore, the legal requirement that ATC has to be prescribed by a hospital doctor [12, 13] was deemed unhelpful. This is because in practice doctors have to complete additional registration forms concerning the need for care. Such a criticism is sound since ATC is designed to support patients with post-hospitalization nursing care needs. Healthcare professionals directly caring for the patient (e.g. nurses, case managers) might be better suited than hospital doctors to assess such needs. Monego and colleagues [16] recommend that general practitioners be authorised - on top of hospital doctors - to prescribe ATC.

Our findings also underlined that 14 days of ATC is a very limited period to achieve the purposes – set out by the law – of restoring patients’ health to pre-hospitalization level and to return home. The regulation does not state the exact number of days for which ATC can be prescribed, but defines that financing is limited to 2 weeks. In case a patient is discharged to rehabilitation, although the insurer needs to approve the cost prior to admission, this discharge option can be prolonged after its initial 14 days upon the request of the physician. Only the Italian-speaking canton provided longer ATC, but exclusively for patients of legal retirement age. That ATC should be prescribed for longer period and its financing should be better structured have been suggested repeatedly [12‐14, 16, 25], and our empirical evidence strongly supports these claims.

For Switzerland, evidence is lacking to substantiate the fears that patients are actually released earlier and with poorer health status [13, 26] due to DRG implementation [18, 32, 33]. However, several of our study participants stressed how nursing homes have to cater for patients with growing medical complexity, hints at possible early discharges because of SwissDRG. Furthermore, the fact that certain nursing homes must accept ATC patients mean additional work for these institutions, including frequent intake-and-release related paperwork, managing the financing structure of ATC, and figuring out how to adjust to the varying medical situations. Since nursing homes traditionally care for older adults who become long-term residents – and for whom they provide mostly assistance with activities of daily living, the challenges our participants noted are somehow not surprising. Having to admit growing numbers of short-time patients who require a higher workload, but whose reimbursement occurs on the same financial basis as other long-term residents, might indeed degrade quality of care for long-term residents.

Although ATC shares commonalities with transitional or intermediate care available in the UK and the US [3, 6, 11], differences lie in the fact that ATC is a discharge option with specific financing and another institution provides the service. The latter element entails that continuity of personnel in the patients’ care is lacking. Another factor worth mentioning is that our participants did not discuss the educational component - in the sense of patient and caregiver empowerment to address medical care – which is often highlighted in the literature [1, 8, 9]. The only exception in this respect was the expressed need that patients and family members receive information about the cost associated with stationary ATC. As noted earlier, cost issues must be clarified at the legal level so that ATC is financed equally nationwide [16].

Our findings underline that a number of issues such as the financing of ATC, its limited duration, and the medical responsibility (i.e. who can prescribe it) need review at the policy level and, potentially, a revision of the existing regulation. Clarifying these concerns will ensure uniform and correct implementation of ATC across the country. As evident in previous research [28, 29] vulnerable patient groups, such as older women and those lacking supplementary insurance, tend to be disproportionately discharged to ATC. A standardized assessment of patients’ needs is critical so that ATC and other discharge options (e.g. rehabilitation) are prescribed uniformly. Such practice will assure equal access to different care options after hospitalization and avoid burdening certain patient groups. Beyond that, there is need for further research to (a) evaluate if ATC is indeed a measure to protect vulnerable patient groups, (b) alleviate the dangers of precocious hospital discharge, and (c) explore how its use is being justified in light of stationary ATC’s cost burden.