Considering the role of context when implementing government policies in hospitals: introduction of a prospective payment system for psychiatry

PurposeThe context in which an innovation is implemented is an important and often neglected mediator of change. A prospective payment system (PPS) for psychiatric and psychosomatic facilities with major implications for inpatient psychiatric care in Germany was implemented from 2013 to 2017. This study aims to examine the determinants of implementation of this government policy using the Diffusion of Innovations theory and consider the role of context.Design/methodology/approachAn exploratory case study was conducted in two wards of a psychiatric hospital in Germany: geriatric psychiatry (GerP) and general psychiatry (GenP). Fifteen interviews were conducted with different occupational groups and analyzed in-depths. Routine hospital data were analyzed for delimiting the two contexts.FindingsRoutine hospital data show a higher day-mix index (1.08 vs. 0.94) in the GerP context and a very different structure regarding PPS groups, indicating a higher patient complexity. Two types of factors influencing implementation were identified: Context-independent factors included social separation between nurses and doctors, poor communication behavior between the groups and a lack of conveying information about the underlying principles of the PPS. Context-dependent factors included compatibility of the new requirements with existing routines and the relative advantage of the PPS, which were both perceived to be lower in the GerP context.Practical implicationsDepending on the patient characteristics in the specific context, compatibility with existing routines should be ensured when implementing. Clear communication of the underlying principles and reduction of organizational and communicative barriers between professional groups are crucial success factors for implementing such innovations.Originality/valueThis study shows how a diffusion process takes place in an organization even after the organization adopts an innovation. The authors could show how contextual differences in terms of patient characteristics result in different determinants of implementation from the views of the employees affected by the innovation.

Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage

Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals. Conclusions The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.

Correction to: Changes in hemodialysis catheter management after introduction of the end-stage renal disease prospective payment system

An amendment to this paper has been published and can be accessed via the original article.

Changes in hemodialysis catheter management after introduction of the end-stage renal disease prospective payment system

Background: We investigated whether implementation of the end-stage renal disease prospective payment system (ESRD PPS) was associated with changes in thrombolytic therapy use and other aspects of catheter management in hemodialysis (HD) patients. Methods: Using quarterly, period prevalent cohorts of patients undergoing maintenance HD with a catheter in the US Renal Data System (2008-2015), we studied rates of claims for within- and outside-HD-unit thrombolytic use, and thrombus/fibrin sheath removal, and rates of delayed HD treatment after ESRD PPS implementation, January 1, 2011. Associations between PPS implementation and change in trend of rates of each outcome were assessed using covariate-adjusted Poisson regression, using a piecewise linear function for quarter-time (with breakpoint at PPS implementation). Results: Among an average of 69,428 quarterly catheter users, rates of claims for within-HD-unit thrombolytic use declined from 236.6 (Q1-2008) to 81.4 (Q4-2012) per 100 person-years ( P < 0.0001, PPS association with change in trend); rates of claims for thrombus/fibrin sheath removal procedures increased from 3.9 (Q1-2008) to 8.8 (Q3-2015) per 100 person-years ( P = 0.0001, PPS association with change in trend). Rates of delayed HD treatment increased from 1.6 (Q2-2008) to 2.3 (Q3-2015) per patient-quarter, although PPS implementation was associated with a decrease in this rising trend (1.6% increase per quarter pre-PPS, 1.2% post-PPS; P < 0.0001, change in trend). Conclusions: After PPS implementation, thrombolytic use decreased and thrombus/fibrin sheath removal increased. The increasing trend in delayed HD treatment appeared to slow after PPS implementation, but delayed sessions continued to increase year over year for unclear reasons.

Changes in hemodialysis catheter management after introduction of the end-stage renal disease prospective payment system

Background We investigated whether implementation of the end-stage renal disease prospective payment system (ESRD PPS) was associated with changes in thrombolytic therapy use and other aspects of catheter management in hemodialysis (HD) patients. Methods Using quarterly, period prevalent cohorts of patients undergoing maintenance HD with a catheter in the US Renal Data System (2008–2015), we studied rates of claims for within- and outside-HD-unit thrombolytic use, and thrombus/fibrin sheath removal, and rates of delayed HD treatment after ESRD PPS implementation, January 1, 2011. Associations between PPS implementation and change in trend of rates of each outcome were assessed using covariate-adjusted Poisson regression, using a piecewise linear function for quarter-time (with breakpoint at PPS implementation). Results Among an average of 69,428 quarterly catheter users, rates of claims for within-HD-unit thrombolytic use declined from 236.6 (Q1–2008) to 81.4 (Q4–2012) per 100 person-years (P < 0.0001, PPS association with change in trend); rates of claims for thrombus/fibrin sheath removal procedures increased from 3.9 (Q1–2008) to 8.8 (Q3–2015) per 100 person-years (P = 0.0001, PPS association with change in trend). Rates of delayed HD treatment increased from 1.6 (Q2–2008) to 2.3 (Q3–2015) per patient-quarter, although PPS implementation was associated with a decrease in this rising trend (1.6% increase per quarter pre-PPS, 1.2% post-PPS; P < 0.0001, change in trend). Conclusions After PPS implementation, thrombolytic use decreased and thrombus/fibrin sheath removal increased. The increasing trend in delayed HD treatment appeared to slow after PPS implementation, but delayed sessions continued to increase year over year for unclear reasons.