Lisa I. Iezzoni, MD, MSc

 Emergency department (ED) crowding poses a severe public health threat, and identifying acceptable means of treating medical conditions in alternative sites of care is imperative. We compared patients’ experiences with in-home urgent care via mobile integrated health (MIH) vs urgent care provided in EDs.

 Survey, completed on paper, online, or by telephone. We surveyed all patients who received MIH care for an urgent health problem (n = 443) and consecutive patients who visited EDs for urgent care (n = 1436).

 Study participants were members of a managed care plan who were dually eligible for Medicare and Medicaid, 21 years or older, and treated either by MIH or in an ED for nonemergent conditions around Boston, Massachusetts, between February 2017 and June 2018. The survey assessed patients’ perceptions of their urgent care experiences.

A total of 206 patients treated by community paramedics and 718 patients treated in EDs completed surveys (estimated 66% and 62% response rates, respectively). Patients treated by MIH perceived higher-quality care, more frequently reporting “excellent” (54.7%) or “very good” (32.4%) care compared with ED patients (40.7% and 24.3%, respectively; 

 < .0001), and were significantly more likely to report that decisions made about their care were “definitely right” compared with patients treated in the ED (66.1% vs 55.6%; 

 Patients appear satisfied with receiving paramedic-delivered urgent care in their homes rather than EDs, perceiving higher-quality care. This suggests that in-home urgent care via MIH may be acceptable for patients with nonemergent conditions.

Patients receiving paramedic-delivered urgent care appear to be more satisfied than patients receiving care in emergency departments.

The majority of patients treated by community paramedics also reported that they would prefer future urgent care in the home with paramedics.

Mobile integrated health and community paramedicine present a patient-accepted alternative to emergency department–based urgent care.

Emergency departments (EDs) are “an impressive public health success story,” according to the National Academy of Medicine, providing emergent care for traumatic, cardiovascular, and cerebrovascular events that saves lives and limits long-term disability.

 Throughout the COVID-19 pandemic and other times of crisis, EDs also serve as the safety net, particularly for persons lacking a usual source of or timely access to care.

 Consequently, EDs are increasingly crowded with patients with emergent and nonemergent needs, raising the imperative to identify approaches for providing care in alternative settings.

Mobile integrated health and community paramedic (MIH/CP) programs offer an opportunity to expand emergency medical service providers’ scope of practice to evaluate and treat patients within their homes or institutional residences (eg, nursing homes) whenever appropriate rather than solely during transport to EDs. Countries around the world employ MIH/CP programs to effectively deliver care.

 However, MIH/CP has not been widely implemented in the United States and is typically used to target specific health conditions (eg, heart failure) or narrowly circumscribed populations (eg, frequent 911 callers, underserved rural areas).

We developed an MIH/CP urgent care model that aimed to reduce preventable ED use and improve urgent, nonemergent care experiences. The program sends specially trained paramedics to evaluate and treat patients with urgent care problems between 6 PM and 2 AM within their homes or institutional residences. Our MIH/CP program is a collaboration between a local ambulance service provider and a nonprofit health insurer–managed health care delivery system in Massachusetts providing fully integrated care (from tertiary care to long-term services and support) to its membership, most of whom are eligible for both Medicare and Medicaid. At the time of this study, our program operated under a Special Project Waiver authorized by the Massachusetts Department of Public Health Office of Emergency Medical Services, covering a catchment area surrounding greater Boston.

The purpose of this study was to learn about how patients perceive their urgent care experiences, comparing the views of persons receiving urgent care via an MIH/CP program vs perceptions of persons visiting EDs. Because this was a new MIH/CP program, we also aimed to understand how patients experienced various aspects of their services. It is important to assess patients’ comfort with receiving care in their residences rather than receiving transportation to EDs. If patients express reluctance to receiving in-home care, the MIH/CP approach to urgent care may not offer a viable alternative to ED-based care.

This research was reviewed and approved by the institutional review boards of both Mass General Brigham (Boston, MA) and University of Massachusetts Boston. It was funded by Patient-Centered Outcomes Research Institute.

No existing survey instruments served our purposes, and we therefore developed our own questionnaires. We involved patient stakeholders in survey design, working closely with the Disability Policy Consortium in Malden, Massachusetts, an organization of disability rights activists promoting inclusion, independence, and empowerment of all individuals with disabilities. We held in-depth, open-ended conversations with 2 lead Consortium staff members, one representing persons with significant physical disability and the other representing persons in recovery from serious mental illness, about urgent care experiences of persons with complex health needs. Based on those interviews, we designed a semistructured interview protocol to gather in-depth experiential information from Commonwealth Care Alliance members who had recently received urgent care services. We enlisted Disability Policy Consortium staff members to conduct, audio-record, and transcribe interviews, ultimately conducting 4 interviews with persons treated in their homes and 5 persons treated in EDs. The researchers conducted thematic analyses of these transcripts to identify topics for survey questions.

We worked with experts at the Center for Survey Research at the University of Massachusetts Boston to develop a survey that would require no more than 10 to 15 minutes to complete. We created distinct but overlapping surveys for each group in order to limit respondent burden and minimize skip patterns. Under supervision from the researchers, staff conducted cognitive testing of the draft instruments, interviewing 3 paramedic-treated and 4 ED-treated patients. We revised the draft surveys based on the cognitive testing and created English-language and Spanish-language versions.

We interviewed Commonwealth Care Alliance members who were dually eligible for Medicare and Medicaid, were 21 years or older, spoke English or Spanish, and had recently (within the prior week) received urgent care services from either community paramedics or an ED. Some members experience more frequent urgent health problems and consequently have more frequent urgent care visits. To reduce respondent burden among those patients with multiple urgent care visits during the study period, we screened all candidate cases against individuals already in the sample following 2 rules: (1) an individual could not be surveyed more than once within a 2-month window; and (2) an individual could not be surveyed more than twice. We identified patients for surveys within 1 week of their urgent care visits.

Within these parameters, we surveyed all persons receiving MIH/CP visits, using paramedic logs. Because members did not always notify Commonwealth Care Alliance when they visited EDs, we used the commercial PatientPing software to identify plan members who had visited the ED during the previous day.

 Before referring candidate cases, clinicians screened each PatientPing-identified encounter to identify urgent care visits that MIH/CP might otherwise have handled (ie, eliminate true emergency and nonurgent care).

We conducted the survey from February 2017 through June 2018. For the fewer than 1% with a valid email address, we emailed the survey description and invitation, promising a $5 incentive for survey completion. For other candidates, we sent a first-class envelope containing an invitation letter, the paper questionnaire, a business reply envelope, and a $5 incentive. If surveys were not returned within 10 to 14 days, we began telephoning survey candidates, using bilingual interviewers for Spanish speakers. On average, our interviewers made 6 to 8 attempts until the interview was completed or the case was deemed ineligible (eg, individual deceased, too sick to participate). When candidates declined participation, our interviewers attempted to identify reasons and, as appropriate, obtain participation by scheduling a convenient interview time.

Not counting ineligible duplicate cases, there were 443 MIH/CP cases and 1436 ED cases targeted for surveys. We received 206 completed MIH/CP surveys and 718 ED surveys (

). Among patients treated by community paramedics, 8% refused participation, 4% had died, and 65% were hospitalized or too ill to participate. Among ED referrals, 10% refused participation, 3% had died, and 66% were hospitalized or too ill to participate. In calculating response rates, we included in the denominator a proportion of cases for which we could not determine eligibility. We estimated response rates at 66% for MIH/CP cases and 62% for ED cases.

We conducted all analyses using SAS software version 9.4 (SAS Institute). We used descriptive statistics to look at frequencies of responses. Comparisons were done via χ

Table 1 shows patients’ demographic characteristics for the 206 MIH/CP visits and 718 ED visits. Patients treated by community paramedics were significantly older than patients seen in the ED, with a mean (SD) age of 66 (17) vs 58 (14) years (

 < .0001). MIH/CP patients were also significantly more likely to be Black or African American (29.1% vs 12.0%; 

 < .0001). There were no significant differences between MIH/CP and standard care patients’ education levels.

 reports responses from all 206 patients treated by MIH/CP, then separately for patients who were (23.8%) or were not (59.7%) ultimately transported to the ED. The 34 respondents with missing variables had difficulty recalling the event. Nearly all patients treated by community paramedics felt the paramedic explained their health problem in an understandable way (94.5%) and treated them with courtesy and respect (99.4%). MIH/CP-treated patients reported that the paramedic did an excellent (54.6%) or very good (32.8%) job caring for their health problem. Patients ultimately transported to the ED reported no statistically significant difference in their perception of how well the paramedic performed in caring for their health problem compared with those patients who received all treatment in their homes (

 = .07). Furthermore, among patients ultimately transported to the ED, almost all (97.9%) felt that the paramedic understood their health problem. More patients transported to EDs (15.2%) reported that the paramedic did not explain things about their health care problem in a way they could understand compared with patients not transported to EDs (1.7%; 

 shows responses from the 718 ED patients about their urgent care experiences. The majority of patients receiving urgent care in EDs felt that the ED staff explained their health problem in an understandable way (86.3%) and treated them with courtesy and respect (92.7%).

Patients treated in EDs reported moderate levels of anxiety prior to care, with 38.0% reporting that they were very anxious (19.0%) or extremely anxious (19.0%) while awaiting care. After arriving in the ED, the vast majority (93.0%) of patients reported that the ED doctors and nurses focused on their health problem rather than their disability (7.0%).

Perceptions of MIH/CP Compared With ED Care

 shows results for questions answered by both MIH/CP and ED patients. Patients treated by community paramedics perceived higher-quality care, more frequently reporting “excellent” (54.7%) or “very good” (32.4%) care compared with ED patients (40.7% and 24.3%, respectively; 

 < .0001). Further, patients treated by community paramedics were significantly more likely to report that decisions made about their care were “definitely right” compared with patients treated in the ED (66.1% vs 55.6%; 

 = .02). Patients treated by community paramedics and patients treated in EDs were asked to respond with their views on the MIH/CP program or a hypothetical MIH/CP urgent care program (for those in the standard care group who did not have the option of a community paramedic visit). Patients treated by community paramedics reported that being treated in an ED would be more stressful (66.7%) than being treated at home (7.4%), whereas ED patients hypothesized rates of 44.0% and 13.8%, respectively (

 < .0001). Significantly more (67.2%) MIH/CP patients than patients receiving ED care (35.9%; 

 < .0001) would prefer future in-home urgent care by community paramedics. Patients treated by community paramedics were more likely than patients receiving ED care to say that in-home treatment by a paramedic saved more time than going to the ED (73.6% vs 53.1%; 

 < .0001) and less likely to say that in-home treatment would also carry a higher risk of becoming sicker (9.2% vs 24.1%; 

Patients with complex health and socioeconomic needs appear more satisfied receiving paramedic-delivered urgent care treatments in their homes and institutional residences rather than in EDs. They also perceived higher-quality care compared with the ED, with nearly 9 of 10 patients treated by community paramedics reporting excellent or very good quality care.

The majority of patients treated by community paramedics also reported that they would prefer future urgent care in the home with paramedics, should the need arise. Interestingly, when patients who received ED care for their urgent need were presented with a hypothetical MIH/CP urgent care program, far fewer (nearly one-third) expressed a similar preference. This difference is striking for 2 reasons. First, among the general population of patients who have received recent urgent care in an ED, more than one-third speculated they would want a hypothetical in-home model rather than ED-based care. This suggests that patients are open to receiving urgent care in alternative settings to the ED. Second, once patients experienced the MIH/CP program, an additional third of patients preferred the alternative to the standard care model. Collectively, this demonstrates that there is both a desire for and satisfaction with the provision of urgent care in alternative settings.

MIH/CP programs are poised to meet this demand and offer opportunities to potentially avoid preventable ED transports and associated hospital admissions. Using Medicare claims from 2005-2009 and linking ambulance transports with ED diagnoses, Alpert and colleagues estimated that 15.6% of 911 emergency medical service (EMS) transports for Medicare beneficiaries were for low-acuity conditions that could have been treated outside EDs. These patients generated slightly more than $1 billion annually in Medicare costs; managing these patients in lower-intensity settings could save an estimated $560 million annually.

 Similarly, Weinick and colleagues estimated that 13.7% to 27.1% of persons across all age ranges seen at EDs could appropriately receive care at freestanding urgent care centers or retail clinics, resulting in concomitant health care system cost savings that would likely only be further compounded with the implementation of MIH/CP programs.

Existing MIH/CP programs in the United States have not been rigorously evaluated among a wide population.

 Programs that have been studied are reducing ED use (one by 58.2% among frequent 911 callers), generally within narrowly defined populations.

 One MIH/CP program in Houston, Texas, found a 56% reduction in transports to the ED for nonurgent, primary care–related complaints and found no statistical difference in mortality or patient satisfaction.

 A community paramedic program sponsored by Northwell Health in New York published an observational study of nearly 1600 patients who reported unanimous satisfaction but no further detail regarding patients’ perceptions or experiences.

Our data offer insight into why patients who experienced care from community paramedics prefer the alternative care model to ED care. Patients treated by community paramedics believed that in-home treatment saved them time compared with going to the ED and that in-home treatment carried a lower risk of their illness worsening. Overall, patients who experienced the program perceived in-home care as less burdensome than ED-based care. There is strong evidence regarding the negative impact of ED crowding on clinical outcomes, mortality rates, treatment times, and rates of patients leaving against medical advice without having received treatment.

 The long wait times of crowded EDs and impaired communication with ED staff reduce patient satisfaction with ED care.

 As such, crowded EDs can be perceived as uncomfortable, inefficient, and even dangerous places to obtain care.

Increasingly, EDs are used as a timely way to access care. The causes of urgent care needs are diverse, ranging from mild trauma to exacerbations or complications of acute and chronic physical and mental health conditions. Some populations are more prone to experience urgent care needs than others due to demographic factors (especially older age), the extent and nature of underlying physical and mental health conditions, attributes relating to “physiologic reserve” (eg, frailty, disability), and other risk factors. Medicaid recipients use EDs for nonurgent care 4 times more often than uninsured Americans. As the US population grew 12% from 1993 to 2003, ED use rose 26%.

 Based on the 2011 National Hospital Ambulatory Medical Care Survey, just 10.7% of ED visits were for emergencies, 42.3% required urgent care, 35.5% required semiurgent care, and 66.6% were told to seek follow-up care with a physician or clinic.

 It is imperative to better match patients’ clinical needs with the appropriate care setting in order to combat the issue of ED crowding.

Historically, CMS and other payers would not reimburse out-of-hospital care (eg, assessments, treatments) without bundling patient transport to EDs.

 As such, EMS systems grew to depend more heavily on ED transport for even nonemergent conditions to support their operations.

 Recognizing the value of an expanded role for paramedics even before the COVID-19 pandemic, in August 2019 CMS announced the Emergency Triage, Treat, and Transport model, a 5-year payment model aimed at providing greater flexibility to ambulance teams to address emergency health care needs.

 This change expands the historic requirement that patients who are evaluated by paramedics must be transported to EDs and further provides a framework to develop MIH/CP programs.

Our findings suggest a promising paramedic-based urgent care alternative that would be acceptable to complex, high-cost patients. Although future research must determine whether longer-term clinical outcomes between an MIH/CP urgent care program and standard ED care are comparable, the response from patients raises the prospect that nonemergent care can be treated in alternative environments with ultimate improvements to patient satisfaction.

This study has important limitations as part of a real-world implementation. ED data were limited and anonymized, lacking time stamps and facility characteristics. As such, potential confounders and subgroup analyses could not be analyzed. The survey groups had several demographic differences, and it is unclear what impact these differences had on the analysis. Additionally, although we excluded repeat surveys to reduce respondent burden, the perspective of the subgroup of patients with multiple encounters was unaccounted for. This survey was also conducted before the COVID-19 pandemic, which facilitated a more rapid expansion of MIH/CP across Massachusetts and may have altered patient perceptions of MIH/CP. As a result, patient experience data related to these programs have greater significance.

Results come from a single health care delivery system in Massachusetts during a pilot under a Special Projects Waiver. Although patients were not randomly assigned to MIH/CP vs ED care, clinicians reviewed cases for clinical comparability, and the rates of deaths and hospitalizations/being too sick to answer were very similar across the 2 groups. The study also only explores how an urgent care community paramedic program appeals to a low-income, medically complex patient population. Future analyses with larger sample sizes would allow more robust subgroup analyses, such as patients transported to the ED following MIH evaluation. Nevertheless, this study contributes valuable information regarding the experiences of patients receiving community-based care from paramedics.

Patients report high levels of satisfaction and perceived higher quality receiving paramedic-delivered urgent care in their homes rather than going to EDs. The overwhelmingly positive feedback that patients reported for paramedic care exceeded expectations, nearing complete satisfaction. MIH/CP represents an alternative care model for delivering urgent care with the prospect of enhancing efficiency while maximizing patient satisfaction. Knowing that patients consider this care model acceptable suggests that it has potential as a capacity management tool, optimizing care delivery and reducing ED crowding. With MIH/CP representing an alternative pathway accepted and even preferred by patients, our analysis of the program’s impact on ED utilization will be forthcoming. As MIH/CP programs expand, continued rigorous investigation and assessment are needed to explore the clinical outcomes, broader health care utilization, and feasibility of implementation in other regions and health care systems.

The authors would like to acknowledge the contributions of Scott Cluett, Matt Goudreau, and Dhruva Kothari, MD, for their integral contributions to the development of this MIH/CP program.

 Department of Emergency Medicine, Massachusetts General Hospital (SCD), Boston, MA; Department of Emergency Medicine (SCD) and Department of Medicine (LII), Harvard Medical School, Boston, MA; Health Policy Research Center, Mongan Institute, Massachusetts General Hospital (AJW, LII), Boston, MA; Department of Sociology and Center for Survey Research, University of Massachusetts – Boston (PSB), Boston, MA; School of Social Work and Center for Aging and Disability Education and Research, Boston University (BK), Boston, MA; Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health (JP), Boston, MA.

 Patient-Centered Outcomes Research Institute Award (IHS-1502-27177).

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (SCD, BK, LII); acquisition of data (SCD, AJW, PSB, BK, JP, LII); analysis and interpretation of data (SCD, AJW, PSB, BK, LII); drafting of the manuscript (SCD, PSB, BK, LII); critical revision of the manuscript for important intellectual content (JP); statistical analysis (JP); provision of patients or study materials (AJW); obtaining funding (LII); administrative, technical, or logistic support (AJW, LII); and supervision (LII).

 Stephen C. Dorner, MD, MPH, MSc, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Email: sdorner@mgh.harvard.edu.

Hospital-Based Emergency Care: At the Breaking Point

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Articles

Comparing patients’ experiences with in-home urgent care from community paramedics vs urgent care provided in emergency departments, we found higher satisfaction among patients receiving in-home treatment.

Patient Perceptions of In-home Urgent Care via Mobile Integrated Health

 Emergency departments (EDs) frequently provide care for nonemergent health conditions outside of usual physician office hours. A nonprofit, fully integrated health insurer/care delivery system that enrolls socioeconomically disadvantaged adults with complex health needs partnered with an ambulance service provider to offer after-hours urgent care by specially trained and equipped paramedics in patients’ residences. The Massachusetts Department of Public Health gave this initiative, the Acute Community Care Program (ACCP), a Special Project Waiver. We report results from its first 2 years of operation.

 We used descriptive methods to analyze administrative claims, financial and enrollment records from the health insurer, information from service logs submitted by ACCP paramedics, and self-reported patient perceptions from telephone surveys of ACCP recipients.

 ACCP averaged only about 1 call per day in its first year, growing to about 2 visits daily in year 2. About 15% to 20% of ACCP patients ultimately were transported to EDs and between 7.2% and 17.1% were hospitalized within 1 day of their ACCP visits. No unexpected deaths occurred within 72 hours of ACCP visits. Paramedics stayed on scene approximately 80 minutes on average. About 70% of patients thought that ACCP spared them an ED visit; 90% or more were willing to receive future ACCP care. Average costs per ACCP visit fell from $844 in year 1 to $537 in year 2 as volumes increased.

 This study using observational data provides preliminary evidence suggesting that ACCP might offer an alternative to EDs for after-hours urgent care. More rigorous evaluation is required to assess ACCP’s effectiveness.

The Acute Community Care Program (ACCP) is a collaboration between a nonprofit, fully integrated health insurer/care delivery system that enrolls socioeconomically disadvantaged adults and an ambulance service provider to offer after-hours urgent care by specially trained and equipped paramedics in patients’ residences. Without ACCP, these patients would typically be sent to emergency departments (EDs). Early results suggest that: 

ACCP appears to reduce ED visits for these urgent care patients. 

At least 90% of patients are willing to receive ACCP care in the future. 

More research is needed to quantify the effects of ACCP on ED use and patients’ experiences.

As managed care programs seek ways to cut costs while improving care quality, reducing emergency department (ED) visits is an obvious target. Most ED visits do not involve medical emergencies, and many patients could safely receive care in less costly and intensive settings.

However, various strategies to decrease ED use among managed care members have yielded mixed results.

 One study of Medicaid managed care found that patients assigned to primary care practices with more than 12 evening hours per week had 20% fewer ED visits than other patients.

 Nonetheless, EDs continue to serve important roles in after-hours care and situations in which primary care clinicians have limited same-day or next-day appointments available.

Here, we describe experiences during the first 2 years of the Acute Community Care Program (ACCP), an innovative program in eastern Massachusetts designed to prevent unnecessary ED visits by providing after-hours nonemergency urgent care to adults with complex care needs.

ACCP represents a collaboration between EasCare, an ambulance service provider, and Commonwealth Care Alliance (CCA), a nonprofit health insurer and integrated healthcare delivery system providing a full range of care, from tertiary care to long-term services and supports. CCA’s care model involves interdisciplinary teams, integrating behavioral and physical health services with extensive community outreach.

All CCA enrollees have Medicaid (MassHealth), the majority also have Medicare, and most care is reimbursed through capitated Medicare and MassHealth payments.

CCA members have complex health and social service needs. Among CCA members 65 years or older and dually eligible for Medicare and MassHealth, approximately 75% are community-dwelling, albeit nursing home—certifiable, according to Medicare criteria; 70% have 4 or more chronic health conditions; and 62% are not primary English speakers. Among enrollees aged 21 to 64 years and dually eligible for Medicare and MassHealth, approximately 70% have behavioral health diagnoses, 15% have current or prior alcohol dependence or substance use disorder, and 7% are homeless, with many others experiencing housing insecurity. CCA enrollees visited EDs 3 times more often than other Massachusetts residents, with average annual ED utilization rates of 810 per 1000 for enrollees 65 years and older and 1564 per 1000 for those aged 21 to 64 years.

 Much of this ED care involved conditions that could have been effectively treated in community settings. Furthermore, ED visits were frequently emotionally uncomfortable for CCA patients, who felt stigmatized by their health conditions or sociodemographic attributes.

 Many ED visits occurred during evening hours, when patients’ primary care clinicians were unavailable for direct patient care.

In July 2014, EasCare and CCA jointly approached the Massachusetts Department of Public Health Office of Emergency Medical Services (OEMS) to obtain a Special Project Waiver to implement ACCP. The waiver allowed pilot testing of ACCP in eastern Massachusetts. ACCP paramedics receive 300 hours of didactic training concerning complex clinical assessments in patients’ homes, interpreting laboratory and other test results, and communicating effectively with on-call clinicians. Trainees’ technical skills and communication competencies are assessed through a multifaceted simulation program that incorporates standardized patients, manikins, direct observation by supervisors and ACCP-trainee paramedic peers, and trainees’ self-assessments.

ACCP started operations in October 2014, serving patients between 6 pm and 2 am. Beginning in late afternoon, CCA members who call their primary care clinician are evaluated by nurses by telephone. Emergency needs, defined as requiring immediate medical attention, are referred to 911 and thus EDs. Urgent needs, defined as nonemergent but requiring attention before the next business day, span a range of acuity and are triaged using a color-coded system to the ACCP paramedic. Paramedics visit the patients with the most severe needs each night, traveling in their specially equipped SUV to patients’ residences.

 To oversee clinical decision making, on-call CCA primary care physicians interact with ACCP paramedics in the field through real-time smartphone communication and shared electronic health records. These CCA physicians are either general internists or family practitioners, experienced in the care of complex patients with a heavy burden of chronic conditions, disability, and sociodemographic disadvantages. In their practices, they sometimes make home visits and therefore appreciate firsthand what the paramedics will confront on scene.

During this ongoing pilot period, Massachusetts’s OEMS monitored ACCP for safety (deaths within 72 hours, postvisit ED transports) and patient satisfaction reports obtained by EasCare. Here, we present these observational data compiled during ACCP implementation. We examine ACCP visits and postvisit service use and deaths, ACCP on-scene activities, and self-reported patient satisfaction. These observational findings provide important preliminary insights into patient outcomes during ACCP’s first 24 months.

The Massachusetts General Hospital/Partners HealthCare Institutional Review Board approved this study.

ACCP Visits, Post-ACCP Hospital Use, and Deaths

CCA received encounter records from EasCare for each ACCP visit. These claims records are linked to CCA member identification numbers, which also link to member enrollment information, claims for all services provided to members, and death dates. We obtained these claims files from CCA and identified numbers of ACCP visits for individual members, ED use, hospital observation unit stays and admissions post ACCP visits, and deaths. Less than 1% of claims did not distinguish between ED visits and observation stays, lumping them into a combined category. We excluded these claims and retained only claims that clearly differentiated the 2 services. We counted claims to quantify the numbers of different visit types and used service dates to identify events within specified time intervals.

EasCare tracks all ACCP visits and patients’ dispositions, recording details about each visit, including arrival time and time on scene; patient’s chief complaint treated by the paramedic, as determined by a senior clinician upon reviewing the record; vital signs; tests performed; medications administered and other interventions; and disposition (eg, treated at home, referred to ED). We obtained this information from EasCare.

Patient-Reported Satisfaction With ACCP Visit

From the outset, CCA and EasCare clinical leaders surveyed ACCP patients to identify patient-reported problems and areas for improvement. Because of the novelty of the program, no existing survey precisely fit their needs. They therefore took questions commonly employed in other patient-reported experience surveys as models and created several new questions specific to ACCP. In addition to a final open-ended question, the survey (available upon request) includes 12 questions on topics such as communication, whether ACCP prevented ED visits, comparing ACCP with ED visits, willingness to use ACCP again, and overall satisfaction with care.

A senior EasCare staff member administered the survey by telephone within 30 days of the ACCP visit. Given the survey’s operational purpose (ie, not research), the numbers of calls made, whether a proxy responded, and refusals to participate were not recorded. After 15 months of conducting the survey, staff recognized that frequent ACCP users were weary of being asked to answer the same survey (ie, some persons were surveyed 2 or 3 times). After January 1, 2016, staff administered the survey only once to patients with ACCP visits. Therefore, before year 2, quarter 2, individual patients could have contributed up to 3 survey responses. EasCare provided us with monthly spreadsheets of survey responses, and we compiled these results. Results here represent all surveys conducted.

To assess the resources required to design and implement ACCP and the costs to operate the program, we examined financial accounting records and interviewed personnel at both EasCare and CCA. We used visit volume and scale by monthly net operating costs retrospectively gathered from the general ledger accounts and payroll records from both EasCare and CCA. EasCare incurs all operating costs of running ACCP and receives a monthly fee from CCA. Given dates of financial information, the cost analysis looked at calendar years 2015 and 2016.

Between October 2014 and September 2016, CCA membership in the region covered by ACCP grew from 8026 (3435 ≥65 years and 4591 aged 21-64 years) to 9223 (4048 and 5175, respectively).

 shows ACCP visits by quarter and services used and deaths within 90 days of the ACCP visit, stratifying by whether patients were 65 years or older or were younger than 65 years. Numbers of ACCP visits have risen over time but not monotonically. In each year, quarter 2 (January-March) includes peak influenza seasons. As assessed by persons visiting EDs within a day of their ACCP encounter, the percentage of ACCP visits that ultimately required ED transports ranged from around 15% to just above 20% over time. Across the 2 years, quarterly percentages of observation stays or hospitalizations within 1 calendar day of the ACCP visit ranged from 1.4% to 5.7% and 7.2% to 17.1%, respectively. Only 3.8% to 11.5% visited EDs within 2 to 3 days after their ACCP service. However, more than one-third of patients in each quarter had another ACCP visit within 90 days, and within 90 days, up to 35% to 50% of ACCP recipients had either observation stays or hospitalizations. Death rates within 90 days varied by quarter, with the highest rate (25%) in year 2, quarter 2 (Table 1). As determined by OEMS reviews, no unexpected deaths occurred within 72 hours of an ACCP visit.

Across the 2 years, various nonspecific conditions, including dizziness, fatigue, pain, headache, and weakness, accounted for one-fourth to one-third of ACCP complaints (

). In year 1, urinary or respiratory conditions were the precipitating complaint in about one-third of cases, and in year 2, respiratory or abdominal conditions accounted for almost one-fourth of ACCP visits. A wide variety of other complaints also occurred. On average, ACCP paramedics spent about 80 minutes on scene. Approximately one-fifth of patients had an intravenous line inserted, one-fourth received medications, and just over one-third had real-time blood tests performed and interpreted using a portable device.

Patients generally reported high satisfaction with their ACCP experiences. 

 shows results from questions with fixed response categories. The survey closed with an open-ended statement: “We would like to hear anything else about the recent visit of the paramedic to your home.” The number of persons surveyed decreased substantially in year 2, for the reasons previously described. Importantly, approximately 70% of respondents thought that the ACCP visit saved them a trip to the ED, as suggested by these quotations from responses to the open-ended question (note that respondents all referred to their paramedic by his first name; all current ACCP paramedics are male):

[Paramedic’s first name] was just great, and this visit certainly saved me a trip to the emergency room. The only thing I didn’t like was the needle, but the medication made me feel much better. It’s great knowing you guys have this service available. Thank you!

I was so happy that I didn’t have to go to the emergency department again. [Paramedic’s first name] was able to evaluate and treat me at home, which was just fantastic. I run the risk of getting sicker in the hospital, let alone all of the wasted time. … Thank you!

I was shocked to see exactly how much the paramedic could actually do in my home, from the [electrocardiogram] and vital signs to the amazing blood testing machine. Thank you! Definitely saved me a trip to the ER.

I can’t stand going to the hospital because I get put in the hall and everyone walks past me! Having [paramedic’s first name] come to my home was fantastic, and it certainly saved me a trip to the emergency room. Thank you!

Even when the paramedic care could not resolve the problem on scene and the patient required ED transport, the open-ended responses suggested that the paramedic’s involvement facilitated the hand-off to ED clinicians and made that process easier for the patient:

A million thanks to [paramedic’s first name] who helped get my mom to the hospital quickly. She was very sick and [paramedic] helped my entire family with the transition to the hospital. She is doing much better, thank you!

Unfortunately, [patient’s name] had to go to the hospital where she was admitted for 3 days. She is doing much better, and we are thankful that [paramedic’s first name] was able to coordinate the transfer to the hospital so seamlessly. Thank you!

In most quarters, at least 90% of patients strongly agreed that they were satisfied with the quality of the paramedic care, and at least 90% strongly agreed they would be willing to receive ACCP care in the future. The following quotations exemplify the views of survey respondents:

This is the best thing to happen to [my uncle] in a long, long time. Your service has prevented at least four trips to the hospital in the month of November alone. Thank you very much!

This is a great service. The guy [paramedic] was very professional, and I felt very relaxed after the visit. I felt like I could talk comfortably with the paramedic, and I didn’t have to go to the hospital. Thank you!

They [the paramedics] are fantastic guys! You need to advertise this program to make it available to more folks who would benefit from it. Thank you!

ACCP start-up costs were approximately $95,000 and included labor costs (training and administration), capital costs (vehicle and equipment), and other costs (ie, licensing, medical supply inventory). The annual operating costs for 2015 and 2016 were $350,000 and $344,000, respectively, and costs per patient encounter in each year were $844 and $537. Because volume increased more than 50% between 2015 and 2016 and costs slightly decreased, the cost per encounter decreased by 36%, suggesting that EasCare has achieved some economies of scale. As volume continues to increase, it is likely that the cost per encounter will decrease until there is a need to increase capacity and incur more costs of a start-up/overhead nature.

ACCP aimed to provide a clinically effective and patient-centered alternative to ED care for patients with urgent health needs during evening hours. From these preliminary data, it appears that ACCP largely succeeded, because less than one-fifth of persons with ACCP visits ended up going to EDs within the same calendar day as their ACCP encounter. Anecdotally, most same-day ED visits that occurred after ACCP visits were initiated by the paramedic in collaboration with the on-call physician, who determined that the patient’s condition warranted more in-depth evaluation and treatment than could be safely provided in the home setting. Of the patients who were treated at home, in most calendar quarters, less than one-tenth visited EDs within 3 days, suggesting that the immediate urgent issue had been effectively addressed by the ACCP visit. Recipients seemed pleased with their ACCP services, with most reporting their belief that ACCP had prevented them from needing ED care.

From these observational data, it appears that ACCP recipients have a heavy burden of disease, as suggested by substantial fractions requiring both ACCP visits and hospitalizations within 90 days. Early in this pilot program, recognizing the significant symptom burden faced by many CCA members with multimorbid chronic conditions and approaching the end of life, CCA and EasCare clinical leaders developed special workflows and training for ACCP paramedics to care for patients with end-of-life symptoms. This involved an expanded formulary, rapid response, and direct interactions between paramedics and palliative care—trained physicians. The relatively high death rates within 90 days of the ACCP encounter likely reflect this end-of-life care initiative, as well as the overall medical complexity of CCA enrollees.

Although 8000 to 9000 CCA members lived in the ACCP catchment area, during its first 2 years of operation, the program served few individual patients and provided relatively small numbers of visits: on average, roughly 1 visit per day in year 1 and slightly under 2 visits per day in year 2. ACCP needed to build awareness and trust with CCA primary care practitioners that the program offered a safe and appealing alternative for after-hours urgent care management compared with reflexively sending patients to EDs. Equally importantly, the paramedics and CCA clinicians leading ACCP needed to learn from their early implementation experiences to improve the program and extend its reach. From its start, ACCP leaders have met every month in a morbidity and mortality (M&M) rounds format, reviewing each patient who required ED transport, was admitted to hospital within 72 hours, or raised special interest. These M&M meetings led to improvements in ACCP practices and program enhancements. Since the ACCP’s inception, lessons learned include the following:

Patients referred for ACCP have wide-ranging acuity. We had to refine our triage practices to prioritize by medical need, making the highest-value use of the paramedics’ time. We developed a color-coded triage system, honing it with experience, to identify the most acutely ill patients, whom paramedics visit first.

Demand for ACCP is highest in the early evening, falling off substantially after midnight. Although our Special Project Waiver provisions currently prevent us from changing hours of operation, we shall staff as required to accommodate this timing of patient demand in the future.

Ensuring seamless communication among all participants is critical. This includes tracking the ACCP SUV’s location and facilitating calls between paramedics in the field and CCA clinicians. Having online access to CCA’s electronic health records allows paramedics to learn about patients before the visit and gives CCA clinicians immediate access to paramedics’ clinical observations, notes, and test results.

Many CCA members with physical disabilities and/or mental illness have experienced discomfort and stigma at EDs and are therefore reluctant to visit them, even with severe symptoms. These individuals frequently wait at home until their illness is so advanced that they risk worse outcomes. Although we originally conceived ACCP to reduce unnecessary ED use, for these members we believe ACCP allows us to intervene earlier, thereby avoiding complications and more severe illness or debility.

Validating these lessons will require further study.

The Acute Community Care Program uses paramedics to provide in-home urgent care after regular business hours, aiming to prevent unnecessary emergency department visits.
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Early Experiences With the Acute Community Care Program in Eastern Massachusetts

Hybrid approaches to case finding show promise as a method to increase the success of care management programs (CMPs). A large healthcare system implemented a hybrid approach in which clinicians review algorithm-generated lists of potential high-risk patients within their practice and select the patients most appropriate for the CMP.  We sought to understand the criteria clinicians used when selecting patients.

 We conducted 20 semi-structured interviews with a convenience sample of primary care clinicians and their care managers from a diverse set of practices.

 Two independent reviewers thematically coded interview responses through an iterative process.

 In addition to clinical need (eg, disease severity or multiple comorbidities), interviewees considered a number of nonclinical patient characteristics that they felt placed patients at risk for suboptimal healthcare utilization and poor adherence. These include patients’ predisposing (eg, health literacy or navigation challenges, physical vulnerabilities, insight regarding their health) and enabling characteristics (eg, social and home environment, coping skills, financial resources). Interviewees also considered patients’ existing linkages with the health system and whether other clinicians were already meeting a patient’s care needs.

In selecting patients for a CMP, clinicians considered patient characteristics that are not easily captured in standard clinical and administrative data. A hybrid approach to case finding concentrates clinician review on patients who meet standard clinical and healthcare utilization criteria, and allows clinicians to incorporate knowledge of patients’ predisposing and enabling characteristics that are not readily maintained in clinical data.

	This study identified the factors that primary care clinicians and care managers considered as they reviewed algorithm-generated patient lists to identify a final set of patients appropriate for care management. 

		In addition to the complexity of patients’ medical conditions, clinicians considered patients’ health literacy, physical vulnerabilities, social and home environment, and coping skills when selecting patients for care management. 

		Clinicians also considered the extent to which patients’ care needs were met by strong existing linkages to care providers outside of the primary care practice.

Healthcare delivery systems are increasingly entering into risk contracts which require healthcare providers to manage the utilization of defined patient populations. Care management programs (CMPs), particularly those based in primary care practices, have become a common strategy to meet the cost containment and quality targets in these contracts. Due to the concentration of costs in persons with multiple chronic conditions, these persons are often selected for care management interventions that aim to enhance the coordination of health services and improve patients’ ability to navigate the health system.

 Appropriate case finding, or the identification of patients most likely to benefit from care management, is key to maximizing the cost-effectiveness and sustainability of CMPs.

Many CMPs rely on quantitative approaches to high-risk patient identification, such as risk prediction models based on prior healthcare utilization and clinical conditions. These approaches typically rely on administrative data, such as billing claims, to predict future healthcare utilization, but are often unable to include more nuanced patient characteristics, including socioeconomic and psychosocial circumstances.

 Claims-based approaches often fall short of identifying the patients who are most likely to engage in and benefit from care management because they are unable to detect factors such as patient willingness to participate or barriers to participation.

 Moreover, use of data-driven algorithms often introduces a time lag between when patients need help and when they are identified for the program.

An alternative strategy is to rely on direct referrals from primary care physicians (PCPs) to identify appropriate patients. This strategy is based on the premise that PCPs know their patients best and can consider patient characteristics not routinely available in administrative data or medical records.

 However, PCPs vary widely in their referral patterns for such programs,

 and concerns have been raised about underselection of patients with poor existing linkages with the healthcare system.

 Finally, physicians with a poor understanding of care management goals or approaches may refer inappropriate patients to these programs.

Hybrid approaches that combine predictive modeling and clinician input have been suggested as a way to overcome the biases and limitations of the individual approaches.

 Prior research has explored the extent to which primary care clinician case finding agrees with predictive modeling case finding,

 but has not examined the added benefit of clinical review of a list of potentially high-risk patients generated from a predictive algorithm. We investigated the contribution of clinician input in the selection of high-risk patients within an active primary care-based CMP using semi-structured interviews of PCPs and their nurse care managers (CM). We were particularly interested in the criteria and patient factors clinicians used in practice when determining which potential high-risk patients within their panel should be targeted for care management. Specifically, we examined the extent to which clinicians considered: 1) patient characteristics that are and are not routinely available in clinical and billing data; and 2) existing patient linkages to other providers within the healthcare system when reviewing lists of potential high-risk patients, and identifying patients appropriate for practice-based care management. We hypothesized that clinician involvement enhanced the case selection process by allowing the inclusion of information about the patients not readily available in administrative data.

Clinicians consider a number of patient predisposing and enabling characteristics not typically available in clinical data systems when selecting high-risk patients for care management.

Lisa I. Iezzoni, MD, MSc

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