Where to treat the older patient? Can Markov models help us better understand the relationship between hospital and community care?

We have previously used Markov models to describe movements of patients between hospital states; these may be actual or virtual and described by a phase-type distribution. Here we extend this approach to a Markov reward model for a healthcare system with Poisson admissions and an absorbing state, typically death. The distribution of costs is evaluated for any time and expressions derived for the mean and variances of costs. The average cost at any time is then determined for two scenarios: the Therapeutic and Prosthetic models, respectively. This example is used to illustrate the idea that keeping acute patients longer in hospital to ensure fitness for discharge, may reduce costs by decreasing the number of patients that become long-stay. In addition we develop a Markov Reward Model for a healthcare system including states, where the patient is in hospital, and states, where the patient is in the community. In each case, the length of stay is described by a phase-type distribution, thus enabling the representation of durations and costs in each phase within a Markov framework. The model can be used to determine costs for the entire system thus facilitating a systems approach to the planning of healthcare and a holistic approach to costing. Such models help us to assess the complex relationship between hospital and community care.