Place strategy

Moving away from emergency services and emergency office care: nothing better than home?

As promising advances in home care delivery evolve, further research, with particular attention to underserved populations, is needed to assess clinical, equity, and economic impacts and to accelerate implementation, if applicable.

Am J Manage care. 2022;28(4):In press

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The COVID-19 pandemic has necessitated several unforeseen transformative changes in the delivery of health care in the United States. One of the most important is the shift from in-person care in the office to care delivered virtually (by phone or computer) or in the patient’s home. In addition to well-studied adjuncts such as telemedicine and home hospitalization, the use of community paramedicine – emergency care provided by paramedics in patients’ homes – is growing rapidly. As is the case with telemedicine, key stakeholders are carefully considering the impact of this innovative delivery model on access, quality of care, patient satisfaction, healthcare equity and spending. medical.

Among populations with access challenges, home care for significant medical conditions is often preferable to a visit to a clinician’s office or emergency department (ED). Unfortunately, few clinicians do home visits. Telemedicine is a rapidly growing care delivery model that is particularly useful when clinical issues can be addressed primarily through conversation and (sometimes) virtual observation. Telemedicine is limited when a physical examination, immediate diagnostic tests, administration of therapies, or nuanced conversations are needed. Lack of access to computer equipment and limited broadband access can limit communication to only the telephone.

In this issue of The American Journal of Managed Care®, Dorner and his colleagues assess the ability of community paramedicine to help fill this void.1 The authors assess patient perspectives on care provided at home by community paramedics for after-hours care for dual-eligibility patients (Medicare and Medicaid) who require urgent (but not emergent) clinical services. This patient population often has access issues, so it is an excellent population to study.

The authors have devoted considerable energy to developing a tool to assess patients’ perceptions of this level of care that could be useful for future evaluations. They also considered all patients in their population who might have sought after-hours emergency care, drawing on paramedic logs and an ED database. This effort led to high survey response rates for the paramedic and usual care cohorts, thereby minimizing potential selection bias.

It’s no surprise that patients would rather receive care at home than a trip to the emergency room. A more unexpected result was that patients perceived the quality of care provided by community paramedics (87% rated the care as excellent or very good) more favorably than the care provided by emergency department clinicians (65% rated the care as excellent or very good). good).

Above all, it is well known that patient satisfaction is not always correlated with the quality of care. Assessments of evidence-based care or other clinical outcome markers were outside the scope of the study. About a quarter of patients seen by paramedics in the study were eventually transported to the emergency room, reflecting a necessary triage step to ensure patients with emerging needs continue to receive an appropriate level of care. However, when problems did not arise, patients preferred the care they received at home: 95% said the paramedic explained their health problems well and 99% said they were treated with courtesy and respect.

The results of this study are compelling but require further study as several states expand the role of community paramedics. In addition to caring for patients with acute clinical problems, other paramedic programs address post-discharge care, scheduled follow-up visits, palliative care, and other needs. As these programs become more widespread, it is important that evaluators measure the impact on equity. While in theory these community paramedicine policies are designed with the goal of reducing inequities among underserved populations, how they are implemented is key to ensuring that this important goal is achieved.

The Paramedicine model of urgent care has significant potential, especially for vulnerable populations who may disproportionately rely on the emergency department for after-hours care. To date, most home-based programs for high-needs, high-cost patients have failed to demonstrate significant reductions in utilization and cost. The programs available vary in the services provided, including chronic disease medical care, patient self-management, coordination of complex services, and meeting social needs. In addition, programs for patients with high health insurance needs (and dual eligibility) often focus on improved coding to increase reimbursement.

One of the unproven benefits of many of these programs is the ability to avoid potentially avoidable emergency department visits when patients begin to clinically decompensate. Since many of these patients appear ill and are medically complicated to begin with, if they present to the emergency room they are likely to be admitted even if they are not far from their usual state of health. The ability to diagnose and treat problems before they spiral out of control and to do so in a more comfortable setting can be a key piece of the still unsolved puzzle of costly patient care.

One of us (NAS) is chief medical officer for an organization that provides home care for Medicaid patients in dire need. In this program, we offered several interventions to deter patients from immediately calling 911 when they initially feel unwell. They include a 24/7 hotline staffed by doctors and nurse practitioners; give patients reminder cards and magnets to call us first; and reinforce after-hours availability at each scheduled home visit. These strategies have had modest success in redirecting patients from seeking care in the emergency department to non-urgent needs. Another promising option worth considering would be to provide non-emergency after-hours care through a community paramedic program.

However, the use of a community paramedicine program has been slow to evolve at the legislative and policy levels in the primary state in which we operate. We suspect that coordinating and funding a community paramedic program may encounter similar obstacles in other locations. The program studied by Dorner and his colleagues was a collaboration between an ambulance provider and a single nonprofit combined care delivery system operated by an insurer, under a waiver from the state of Massachusetts. This would be the ideal setting to operate community paramedicine for the population in need. Other communities should explore similar collaborations to support this population in need where local resources, regulations and insurance relationships can optimize this response.

The COVID-19 pandemic has forced several significant changes in the delivery of health care in the United States, some of which address long-standing access and quality gaps, well-established health care disparities, and inefficiencies in spending. Innovations that can deliver clinically indicated, high-quality care in a patient’s home rather than during a visit to an emergency department or clinician’s office would be welcome. As these promising advances spread and evolve, further research, with particular attention to underserved populations, is needed to assess their clinical, equity, and economic impacts and to accelerate implementation, optionally.

Affiliation of authors: MedZed (NAS), San Francisco, CA; Department of Internal Medicine, University of Michigan School of Medicine (AMF), Ann Arbor, MI.

Source of funding: Nothing.

Author Disclosures: Dr. Solomon is co-founder, board member and chief medical officer of MedZed, a home care practice for high-risk patients like those seen in the referenced study. Dr. Fendrick reports consulting fees from AbbVie, Bayer, Centivo, Covered California, Emblem Health, Exact Sciences, GRAIL, Harvard University, Health & Wellness Innovations, Health at Scale Technologies, HealthCorum, Hygieia, MedZed, Merck, Mother Goose Health, Phathom Pharmaceuticals, Semper Health, Silverfern Health, State of Minnesota, Teledoc Health, US Department of Defense, Virginia Center for Health Innovation, Wellth, Wildflower Health, Yale–New Haven Health System, and Zansors; research support from the Agency for Healthcare Research and Quality, Arnold Ventures, Boehringer Ingelheim, Gary and Mary West Health Policy Center, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, PhRMA, Robert Wood Johnson Foundation, and State of Michigan/ CMS; and as co-editor of The American Journal of Managed Care®member of the Medicare Evidence Development & Coverage Advisory Committee and partner of V-BID Health, LLC.

Author Information: Concept and design (NAS, AMF); data analysis and interpretation (NAS); drafting of the manuscript (NAS, AMF); and critical revision of the manuscript for important intellectual content (NAS, AMF).

Address correspondence to: A. Mark Fendrick, MD, University of Michigan, 2800 Plymouth Rd, Bldg 16, Floor 4, 016-400S-25, Ann Arbor, MI 48109-2800. Email: [email protected]

REFERENCE

1. Dorner SC, Wint AJ, Brenner PS, Keefe B, Palmisano J, Iezzoni LI. Patient perceptions of urgent care at home via integrated mobile health. Am J Manager Care. 2022;28(4):152-158. doi:10.37765/ajmc.2022.88859