Shifting Away From Emergency Department and Office-Based Urgent Care: No Place Like Home?

Am J Manag Care. 2022;28(4):145-146. https://doi.org/10.37765/ajmc.2022.88857

The COVID-19 pandemic has necessitated several unanticipated transformative changes to health care delivery in the United States. Among the most important is a shift in venue from in-person, office-based care to care delivered virtually (by telephone or computer) or in the patient’s home. In addition to the well-studied adjuncts such as telemedicine and hospital-at-home, the use of community paramedicine—urgent care delivered by paramedics in patients’ homes—is growing rapidly. As is the case for telemedicine, key stakeholders are carefully scrutinizing the impact of this innovative delivery model on access, quality of care, patient satisfaction, health care equity, and medical expenditures.

Among populations who face access challenges, home-based care for significant medical problems is often preferable to visiting a clinician’s office or emergency department (ED). Unfortunately, few clinicians make house calls. Telemedicine is a rapidly growing care delivery model that is particularly useful when clinical issues can be mediated mainly through conversation and (sometimes) virtual observation. Telemedicine is limited when physical examination, immediate diagnostic testing, administration of therapies, or nuanced conversations are required. Lack of access to computer hardware and limited broadband access may restrict the communication only to telephone.

In this issue of The American Journal of Managed Care^®, Dorner and colleagues assess the ability of community paramedicine to help fill this void.¹ The authors evaluate patient perspectives of care delivered in the home by community paramedics for after-hours care for dually eligible (Medicare and Medicaid) patients 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 spent significant energy developing a tool to assess patient perceptions of this level of care that could be useful for future assessments. They also accounted for all patients in their population who may have sought urgent care after hours, relying on paramedicine logs and an ED database. This effort led to high survey response rates for both the paramedicine and usual care cohorts, minimizing potential selection bias.

It is not surprising that patients preferred receiving care in the home over a trip to the ED. A more unexpected finding was that the patients perceived the quality of care from community paramedics (87% rated care excellent or very good) more favorably than the care provided by ED clinicians (65% rated care excellent or very good).

Importantly, it is well known that patient satisfaction does not always correlate with quality of care. Assessments of evidence-based care or other markers of clinical outcome were beyond the scope of the study. About a fourth of the patients seen by paramedics in the study were ultimately transported to the ED, reflecting a triage step required to ensure that patients with emergent needs continued to receive an appropriate level of care. When problems were not emergent, however, 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 findings from this study are compelling but require further study as several states expand the role of community paramedicine. In addition to caring for patients with acute clinical issues, other paramedicine programs address postdischarge care, scheduled follow-up visits, palliative care, and other needs. As these programs become more prevalent, it is important that evaluators measure the equity impact. Although in theory these community paramedicine policies are designed with an eye toward reducing inequities among underserved populations, how they are implemented is critical to ensure that this important goal is achieved.

The urgent care paramedicine model has significant potential, especially for vulnerable populations who may disproportionally rely on the ED for after-hours care. To date, most in-home programs for high-need, high-cost patients have failed to demonstrate significant reductions in utilization and cost. Available programs vary in services provided, including medical care of chronic conditions, patient self-management, coordination of complex services, and addressing social needs. In addition, programs for high-need Medicare (and dual-eligible) patients often focus on enhanced coding to increase reimbursement.

One of the unproven benefits of many of these programs is the ability to avoid potentially preventable ED visits as patients begin to clinically decompensate. Since many of these patients appear sick and are medically complicated at baseline, if they present to the ED they are likely to be admitted even if not far from their usual state of health. The ability to diagnose and treat problems before they spiral out of control and to do it in a more comfortable setting may provide a key piece of the still unsolved puzzle of high-cost patient care.

One of us (N.A.S.) serves as chief medical officer for an organization that provides home care for high-need Medicaid patients. In this program, we have offered several interventions to deter patients from immediately calling 911 when they initially feel unwell. They include a 24/7 phone line staffed by doctors and nurse practitioners; giving patients reminder cards and magnets to call us first; and reinforcing the after-hours availability at every scheduled in-home visit. These strategies have had modest success in redirecting patients from seeking ED care for nonemergency needs. An additional promising option worth considering would be to provide nonemergent after-hours care through a community paramedicine 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 paramedicine program may have similar barriers in other locales. The program studied by Dorner and colleagues was a collaboration between an ambulance provider and a unique nonprofit combined insurer–managed care delivery system, under a waiver by the state of Massachusetts. This would be the ideal setting to exploit community paramedicine for the high-need population. Other communities should explore similar collaborations to support this high-need population where local resources, regulations, and insurance relationships can optimize this intervention.

The COVID-19 pandemic has compelled several significant changes to US health care delivery, some of which address long-existing 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 instead of during a visit to an ED or clinician’s office would be most welcome. As these promising advances disseminate and evolve, further research—with special attention to underserved populations—is needed to assess their clinical, equity, and economic impacts and to accelerate implementation where appropriate.

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

Source of Funding: None.

Author Disclosures: Dr Solomon is cofounder, 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, Sempre 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 serving as co-editor-in-chief of The American Journal of Managed Care^®, member of the Medicare Evidence Development & Coverage Advisory Committee, and partner of V-BID Health, LLC.

Authorship Information: Concept and design (NAS, AMF); analysis and interpretation of data (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: amfen@med.umich.edu.

REFERENCE

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