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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
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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
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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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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).

ACCP Use and Post-ACCP Outcomes

Table 1 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.

Conditions Treated and Interventions

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

Patient-Reported Experiences

Patients generally reported high satisfaction with their ACCP experiences. Table 3 (part A and part B) 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 Costs

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.

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