By Dorothy Brooks
Why do some patients keep visiting the emergency department (ED) when there are better healthcare alternatives to address their medical concerns? Difficulty navigating a complicated health system or not having a primary care provider are two common reasons, but there are countless other issues that may be contributing factors as well. It is a problem, though, because not only is emergency care expensive, but frequent use of the ED is a strong indication that a patient’s care needs are not being met. Furthermore, repeated use of the ED leads to frustration on the part of both patients and emergency care staff.
While there may not be a one-size-fits-all solution to frequent ED use, the University of Virginia (UVA) Health System in Charlottesville has found that its new community paramedicine program is making a measurable difference in the problem. Indeed, in the first year of the program, administrators say that among patients enrolled in it, the average number of ED visits declined from eight visits in the 180 days prior to enrollment to just three visits in the 180 days after patients completed the program.
While the program is deployed through UVA’s Population Health Department, it is designed to work with patients who frequent the ED for non-emergency medical concerns. “Sometimes we hear from EMS agencies as well,” explains George Lindbeck, MD, an associate professor of emergency medicine at UVA and the medical director of the community medicine program. “They will get in touch with us about the fact that they’re responding to calls at a specific address every couple of days and sometimes every day, and so we will follow up with them, but most of our referrals do come from the ED.”
In fact, when the program first started nearly two years ago, a member of the community paramedicine team was strategically stationed at UVA Medical Center to get an early read on potential candidates for enrollment. “What that person would do is field referrals to the program, and secondly, meet with the people, talk to them a little bit [about the program], and get their consent to participate,” states Lindbeck.
Frequent ED use is one indication that a patient might be a good fit for the program because it often signifies that things are just not working out well with their care plan, observes Lindbeck. “Our hope is that if we make contact with them, intervene, and then their ED visits decrease, that will be a marker that they’re doing better with their care plan, and that they are happier and healthier,” he says.
Given that the hospital-based position is temporarily vacant, most patients enrolled in the program now receive their first introduction to the program from one of the two prehospital providers who serve on the community paramedicine team in the field. These providers regularly review lists of patients who frequent the ED, and they also regularly receive information and referrals from the ED staff.
“We normally try to walk through the ED and talk to staff, and we’ll also go to see patients who we are currently working with, have worked with in the past, or people that we’re looking to work with,” explains Patrick Watson, NRP, one of the two prehospital providers serving on the community paramedicine team. “The ED staff members are aware of our program … and if they see [a good candidate for the program] before he hits our radar — or even sometimes patients we are trying to connect with but have not been able to reach by phone — they’ll even try to talk with the patient [about the program] and tell him to expect a call or a visit from us.”
Watson acknowledges that one of the biggest challenges is actually reaching the patients because some of them do not have working phones and some do not even have a permanent address. Consequently, they will work through MyChart to let any care providers who work with these patients know that they are trying to reach them.
“If a patient is still in the ED, we will definitely try to meet with him or her there, but typically we call them and explain that this is a new program, it is free to them, and that we’re hoping to work with them to help them stay home and feel better and not have to be in the ED so much,” explains Taylor Tereskerz, AS, EMT-I, the other member of the community paramedicine team.
Once the paramedicine team contacts patients and explains the program, most readily agree to participate, observes Tereskerz. The next step involves meeting with the patient in person at their home to assess their healthcare needs and challenges in accessing care. “The main goal is to try to help educate them on all aspects of how best to take care of themselves so that they are not requiring as much care,” observes Tereskerz. “On top of that, [we explain] what care destinations are best for what they’re experiencing.”
Tereskerz states that a lot of the team’s success in working with patients has come from their involvement in coordinating care with the patients’ providers. “We try to keep them all informed about what is going on with their patients,” he says. “We can route all of our [information] to them and work to make sure patients are adhering to their medications and their treatment plans.”
This exchange of information is facilitated through a specific type of encounter that was developed for the program in the Epic electronic medical record (EMR) that UVA uses. “I felt strongly from the beginning that I wanted the program to be recognizable as a distinct program here at UVA … and, secondly, I wanted other members of the care team to be able to see [the paramedicine team’s] notes,” explains Lindbeck. “It makes it easy for the community paramedics to get information to the rest of the healthcare team.”
One aspect of the community paramedicine team’s work is making sure patients understand that the ED is not the place for primary care. “We want them to be able to take care of themselves independently so that they don’t have to use the ED as a crutch and put more strain on the 911 system,” adds Tereskerz. “We do a full evaluation of the social determinants of health on each patient who comes into the program, and then we can make referrals based on their needs.”
For example, the team can arrange for transportation so that patients can get to any healthcare appointments; they work with a local charitable organization to provide patients in need with working phones; and they also know how to link patients with various food banks and housing resources.
However, the paramedicine team runs into all kinds of unique situations that they can work through as well. For example, Tereskerz recalls one young adult in his mid-20s who kept returning to the ED for headaches. “He had come into the ED about 13 times, so we started working with him pretty quickly, and realized that he couldn’t see very well; things were blurry,” he says.
Figuring that the vision problems might be what was causing the headaches, the paramedicine team helped to facilitate a visit with an optometrist. This resulted in the young man obtaining glasses. “That was over 10 months ago … and to my knowledge, the man hasn’t been back to the ED since,” states Tereskerz.
Another case involved a woman who was having trouble managing her medications. “We made a referral to a local pharmacy that will deliver medications by dose already presorted,” says Wilson, noting that all the doses are labeled by date and time so that it is clear whether the medications should be taken in the morning, afternoon, or evening.
One case that stands out to Lindbeck involved a woman who was treated in the ED for fall. When she was discharged, the paramedicine team visited her trailer home. “They found that the entrance to her trailer was a tire with a piece of plywood on it,” he says. “That was what she had fallen on — she fell trying to get into her trailer.”
Consequently, within a day, the paramedic team arranged for a carpenter to come out and build steps to get into the trailer. It was an easy solution, but one that would guard against the woman experiencing another fall, explains Lindbeck.
While the paramedics are equipped with the tools to take vital signs, they are more focused on healthcare navigation than care delivery, notes Lindbeck. “We’re not trying to provide home health services,” he says. “We’re out there to try to assess the [healthcare] situation and figure out how we can make it work better.”
Given that the program itself does not generate revenue, Lindbeck works with the paramedic team members to make sure they are documenting what they are doing, with a particular spotlight on costs they are avoiding. “In general, we’re seeing 80% and 90% reductions in ED visit rates for the patients that we have enrolled in the program,” observes Lindbeck.
While impressive, it still is not enough to make a big impact on volume in an ED that sees 210 to 220 patients a day, acknowledges Lindbeck, but he notes that avoided hospital admissions are more significant. “We admit about 45 patients a day from our ED, so three fewer admissions would be measurable,” he says.
Typically, patients remain in the program for 30 to 60 days, with the paramedicine team maintaining a roster of 20 to 25 actively enrolled patients, although some patients like maintaining contact with the team even beyond their active participation, shares Lindbeck. “The [paramedicine team] forms a relationship with these people … and once they’ve been out to their homes a few times, there is a real bond there and people trust them,” he shares.