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The American Journal of Managed Care September 2018
Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study
Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes
Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
Hepatitis C Care Cascade Among Persons Born 1945-1965: 3 Medical Centers
Joanne E. Brady, PhD; Claudia Vellozzi, MD, MPH; Susan Hariri, PhD; Danielle L. Kruger, BA; David R. Nerenz, PhD; Kimberly Ann Brown, MD; Alex D. Federman, MD, MPH; Katherine Krauskopf, MD, MPH; Natalie Kil, MPH; Omar I. Massoud, MD; Jenni M. Wise, RN, MSN; Toni Ann Seay, MPH, MA; Bryce D. Smith, PhD; Anthony K. Yartel, MPH; and David B. Rein, PhD
“Precision Health” for High-Need, High-Cost Patients
Dhruv Khullar, MD, MPP, and Rainu Kaushal, MD, MPH
From the Editorial Board: A. Mark Fendrick, MD
A. Mark Fendrick, MD
Health Literacy, Preventive Health Screening, and Medication Adherence Behaviors of Older African Americans at a PCMH
Anil N.F. Aranha, PhD, and Pragnesh J. Patel, MD
Currently Reading
Early Experiences With the Acute Community Care Program in Eastern Massachusetts
Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD
Fragmented Ambulatory Care and Subsequent Healthcare Utilization Among Medicare Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
High-Touch Care Leads to Better Outcomes and Lower Costs in a Senior Population
Reyan Ghany, MD; Leonardo Tamariz, MD, MPH; Gordon Chen, MD; Elissa Dawkins, MS; Alina Ghany, MD; Emancia Forbes, RDCS; Thiago Tajiri, MBA; and Ana Palacio, MD, MPH
Adjusting Medicare Advantage Star Ratings for Socioeconomic Status and Disability
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; Cheryl L. Damberg, PhD; Ann Haas, MS, MPH; Mallika Kommareddi, MPH; Anagha Tolpadi, MS; Megan Mathews, MA; and Marc N. Elliott, PhD

Early Experiences With the Acute Community Care Program in Eastern Massachusetts

Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD
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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ABSTRACT

Objectives: 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.

Study Design: This was an observational study.

Methods: 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.

Results: 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.

Conclusions: 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.

Am J Manag Care. 2018;24(9):e270-e277
Takeaway Points

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. 
  • No unexpected deaths occurred. 
  • 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.1,2 However, various strategies to decrease ED use among managed care members have yielded mixed results.3-7 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.6 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.7

Background

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.8 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.9 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.10 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.8 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.8 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.

Goals and Importance

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.


 
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