Care Coordination in Interhospital Transfer: Different Transfer Types, Coordination Mechanisms, and Destination Choice Strategies

Interhospital transfer (IHT) is common in care delivery. As a form of care transition, IHT faces coordination challenges and can negatively affect care outcomes. Understanding the underlying reasons and the associated operational challenges of different IHT types can help hospital managers design mitigation mechanisms to improve the IHT care outcomes. Existing studies generally find that IHT has unfavorable impacts on care outcomes. However, different IHT types may be associated with distinct coordination characteristics, and thus they may have different impacts on care outcomes. How to differentiate IHT types, both conceptually and empirically? How do different IHT types affect hospital care outcomes? This dissertation attempts to develop a conceptual and empirical method to differentiate two IHT types, namely clinical transfer (due to hospitals’ limited service scope) and non-clinical transfer (due to other factors such as temporary unavailability of staffed beds), from a service design perspective and compare care outcomes associated with the two IHT types. A lot of the errors and failures in healthcare happen during care transitions. Inadequate coordination is frequently cited as a root cause of care quality problems. As such, care coordination has long been identified to be critical to transition of care as patients transfer between different locations or different levels of care within the same location. IHT inherently involves care transition between hospitals, and it is critical to identify coordination mechanisms that could improve IHT outcomes. What coordination mechanisms can hospitals use to improve IHT coordination? Do they impact different transfer types differently? This dissertation strives to examine three coordination mechanisms, namely system affiliation, transfer routinization, and electronic health record (EHR) interoperability, and evaluates their mitigation effects on care outcomes of clinical versus non-clinical transfers. My dissertation first conceptually differentiates between clinical and non-clinical transfers based on their unique characteristics. Then, we develop our hypotheses about the impacts of IHT types on care outcomes and the mitigation effects of the coordination mechanisms. Next, we develop a method to empirically separate the two IHT types using patient-level discharge data and test their impacts on care outcomes, including length of stay (LOS), readmission, and mortality. We find that non-clinical transfers have worse care outcomes than clinical transfers, perhaps due to their inadequate care coordination. We also find that the three coordination mechanisms are associated with improved IHT outcomes, and two of them seem to have stronger effects for non-clinical transfers. Specifically, system affiliation and transfer routinization can reduce LOS and readmission for non-clinical transfers. Further, we find that EHR interoperability has universally positive effects on both IHT types. We perform several robustness checks to address concerns on transfer type classification, sample selection bias, and workload impacts, etc. The results are consistent. My dissertation uncovers IHT care coordination characteristics neglected in the literature and offer valuable insights to hospital managers for improving IHT care outcomes. The findings can shed light on the operations natures of IHT and provide hospital managers with coordination tools that can improve care outcomes.