A description of the vertical integration of acute and post-acute care and its impact on patients with stroke in California, 1997 to 1998

The consolidation of healthcare in the United States has been a rapid process of the past two decades. One aspect of this consolidation, the vertical integration of acute and post-acute care inpatient services, has received relatively little attention. Most work in this area has emphasized the financial benefits without focusing on the potential clinical benefits accruing from vertical integration.; In this dissertation, I review the theory of vertical integration, present a conceptual model of vertical integration, and test the impact of vertical integration on stroke, a highly prevalent acute illness that accounts for forty percent of all institutional rehabilitation admissions. Using an investigator-initiated survey of stroke providers in California combined with area-, hospital-, and patient-level administrative data, I examined vertical integration's relationship to stroke service availability and continuity and its impact on stroke processes of care and patient outcome among individuals hospitalized in California hospitals between 1997 and 1998.; In analyses of the provider surveys, most hospitals appear to offer similar amounts of services though hospitals with more integrated stroke care exhibit report greater service continuity and report higher average number of hours of rehab care for stroke patients during acute hospitalizations. Regression models of individual patient discharge data indicate greater access to rehab care and greater overall use of institutional post-acute care in more integrated hospitals. Among patients discharged to rehab, those from more integrated care settings have shorter hospitalizations and fewer inpatient complications. Explicit procedure use was linked to patient but not hospital factors.; Vertical integration appears to increase access and decrease time to rehab care without altering patient outcomes or increasing subsequent institutional care. A comprehensive examination of the impact of vertical integration across the spectrum of inpatient and ambulatory rehab care with additional (functional) outcome measures will help determine the overall success of this movement in healthcare.