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Early Experiences With the Acute Community Care Program in Eastern Massachusetts
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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
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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DISCUSSION

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:
  1. 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.
  2. 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.
  3. 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.
  4. 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.

Limitations

This observational report has significant limitations for evaluating the effectiveness of ACCP. Most importantly, we do not have a comparison group for judging post-ACCP service use or satisfaction with care. Believing that ACCP truly offers value to its recipients, CCA leadership has dismissed the possibility of randomly assigning persons with after-hours urgent health problems to ACCP versus the standard approach of ED transport. Therefore, any study of ACCP effectiveness will need to use quasi-experimental methods. EasCare staff members administered the patient survey, potentially biasing participants’ responses in the highly positive direction found (eg, because of social desirability bias). Finally, the generalizability of ACCP has yet to be tested.

CONCLUSIONS

Despite its limitations, this report offers preliminary insight into ACCP, with findings suggesting that the program may be able to largely replace the after-hours ED visits that have been standard care for CCA’s complex patients with urgent care needs. This early sense of success has lead CCA and EasCare leadership to develop ideas for extending the program, in addition to expanding it to central and western Massachusetts. Other clinical areas under active consideration include care of homeless populations, opioid-directed programs, monitoring following hospital or rehabilitation facility discharge, telehealth, and veterans’ healthcare initiatives. Systematic evaluation will be required to assess the effectiveness of ACCP’s initial urgent care initiative and expansion programs using this care model.

Author Affiliations: Mongan Institute Health Policy Center, Massachusetts General Hospital (LII, AJW), Boston, MA; Department of Medicine, Harvard Medical School (LII, BBB), Boston, MA; EasCare LLC (WSC), Dorchester, MA; Commonwealth Care Alliance (TA, MG), Boston, MA; Division of General Internal Medicine, Brigham and Women’s Hospital (BBB), Boston, MA; Data Coordinating Center, Boston University (JP, YT), Boston, MA.

Source of Funding: This work was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (IHS-1502-27177).

Author Disclosures: Dr Iezzoni was a member of the board of Commonwealth Care Alliance (CCA) until July 6, 2017, and received grants as principal investigator (PI) on the PCORI contract that funded this work. Mr Cluett is employed by EasCare Ambulance, which owns and operates the mobile integrated health program. Dr Ajayi is an employee of CCA, the nonprofit organization that developed the program researched here; she was also a co-PI on the PCORI contract. Mr Goudreau reports employment and meeting/conference attendance for EasCare Ambulance. Dr Blanchfield is employed by Partners Health Care, which contracts with CCA to care for Medicaid accountable care organization patients. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LII, MG, BBB); acquisition of data (LII, AJW, WSC, MG, BBB, JP); analysis and interpretation of data (LII, AJW, WSC, MG, BBB, JP, YT); drafting of the manuscript (MG, BBB, YT); critical revision of the manuscript for important intellectual content (TA, MG); statistical analysis (JP, YT); provision of patients or study materials (WSC); obtaining funding (BBB); administrative, technical, or logistic support (LII, AJW, WSC); and supervision (LII).

Address Correspondence to: Lisa I. Iezzoni, MD, MSc, Mongan Institute Health Policy Center, Massachusetts General Hospital, 100 Cambridge St, Ste 1600, Boston, MA 02114. Email: liezzoni@mgh.harvard.edu.
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