The contribution of case mix, skill mix and care processes to the outcomes of community hospitals: a population-based observational study

Background: New organizational models to face the unmet needs of frail patients are needed. Community hospitals (CHs) could foster integration between acute and primary care. The aim of this study was to investigate which characteristics of the patients and which care processes affect clinical outcomes, in order to identify who could benefit the most from CH care. Methods: This study included all patients aged 65 and older and discharged in 2017 from the 16 CHs of Emilia-Romagna, Italy. Data sources were the regional CH informative system and hospital discharge records. CH skill mix and processes of care were collected with a survey. The study outcome was variation of the Barthel index (BI). We performed a 2-level random-intercept logistic regression analysis, and used the variance partition coefficient (VPC) to quantify the proportion of BI improvement that lay at CH level. Results: Of the 13 CHs, 8 had a general practitioner medical support model, and 6 had >12 nurses working hours/week/bed. Overall, 53% of the patients had a BI improvement of 10 or more. The patient case mix explained a portion of variability across CHs. Skill mix and processes of care were not associated with BI change. Conclusions: Patients characteristics explained part of between-CH variation in BI improvement. Professional skill mix and processes of care, albeit fundamental to achieve appropriate care and respond to the unmet needs of the frail elderly, did not account for differences in CH-specific outcomes.