Models addressing urgent clinical needs for older adults with multiple advanced chronic conditions are lacking. This observational study describes a Community Paramedicine (CP) model for treatment of acute medical conditions within an Advanced Illness Management (AIM) program, and compares its effect on emergency department (ED) use and subsequent hospitalization with that of traditional emergency medical services (EMS). Community paramedics were trained to evaluate and, with telemedicine-enhanced physician guidance, treat acute illnesses in individuals' homes. They were also able to transport to the ED if needed. The CP model was implemented between January 1, 2014, and April 30, 2015 in a suburban-urban AIM program. Participants included 1,602 individuals enrolled in the AIM program with high rates of dementia, decubitus ulcers, diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease. Participants had a median age of 83 and an average of five activity of daily living dependencies (range 0-6). During the study period, there were 664 CP responses and 1,091 traditional EMS transports to the ED among 773 individuals. Only 22% of CP responses required transport; 78% were evaluated and treated in the home. Individuals that community paramedics transported to the ED had higher rates of hospitalization (82.2%) than those using traditional EMS (68.9%) (P < .001). Post-CP surveys showed that all respondents felt the program was of high quality. Results support the potential benefits of CP and invite further evaluation of this innovative care model.
Objectives As the US population ages and healthcare reimbursement shifts, identifying new patient-centred, cost-effective models to address acute medical needs will become increasingly important. This study examined whether community paramedics can evaluate and treat, under the direction of a credentialed physician, high acuity medical conditions in the home within an advanced illness management (AIM) practice. Methods A prospective observational study of an urban/suburban community paramedicine (CP) programme, with responses initiated based on AIM-practice protocols and triaged prior to dispatch using the Advanced Medical Priority Dispatch System (AMPDS). Primary outcome was association between AMPDS acuity levels and emergency department (ED) transport rates. Secondary outcomes were ED presentations at 24 and 48 hours post-visit, and patient/caregiver survey results. results 1159 individuals received 2378 CP responses over 4 years. Average age was 86 years; dementia, heart failure and asthma/ chronic obstructive pulmonary disease were prevalent. Using AMPDS, most common reasons for dispatch included 'breathing problems' (28.2%), 'sick person' (26.5%) and 'falls' (13.1%). High acuity responses were most prevalent. 17.9% of all responses and 21.0% of high acuity responses resulted in ED transport. Within 48 hours of the visit, only 5.7% of the high acuity responses not initially transported were transported to the ED. Patient/caregiver satisfaction rates were high. conclusion Community paramedics, operating within an AIM programme, can evaluate and treat a range of conditions, including high acuity conditions, in the home that would typically result in ED transport in a conventional 911 system. This model may provide an effective means for avoiding hospital-based care, allowing older adults to age in place.on July 4, 2020 by guest. Protected by copyright.
Background and Objectives Older adults with multiple comorbidities experience high rates of hospitalization and poor outcomes from Coronavirus Disease 2019 (COVID-19). Changes in care utilization by persons in advanced illness management (AIM) programs during the COVID-19 pandemic are not well known. The purpose of this study was to describe changes in care utilization by homebound AIM patients in an epicenter of the COVID-19 pandemic before and during the pandemic. Research Design and Methods Descriptive statistics and tests of differences were used to compare care utilization rates, including emergency department (ED) and inpatient admissions, acute and sub-acute rehabilitation, and AIM program utilization during the pandemic with rates one year prior. Results Acute and post-acute utilization for enrollees (n=1,468) decreased March-May 2020 compared to one year prior (n=1,452), while utilization of AIM program resources remained high. Comparing 2019 and 2020, ED visits/1000 enrollees were 109 versus 44 (p<0.001), inpatient admissions 213 versus 113 (p<0.001), and rehabilitation facility admissions 56 versus 31 (p=0.014); AIM program home visits were 1935 versus 276 (p<0.001), remote visits (telehealth/telephonic) 0 versus 1079 (p<0.001), and all other phone touches 3032 versus 5062 (p<0.001). Home hospice admissions/1000 increased: 16 to 31 (p=0.011). Discussion and Implications Our results demonstrate decreased acute and post-acute utilization, while maintaining high levels of connectedness to the AIM program, amongst a cohort of homebound older adults during the COVID-19 pandemic compared with one year prior. While further study is needed, our results suggest that AIM programs can provide support to this population in the home setting during a pandemic.
Smaller nursing homes, as measured by average residentsʼ daily census, were less likely to report COVID-19 data (odds ratio (OR) =0.96; P < .001). Nonchain nursing homes were less likely to report data (OR = 0.74; P = .001). When comparing nursing homes with four-star quality ratings, nursing homes with three-star ratings were less likely to follow instructions and report COVID-19 data to CMS (OR = 0.75; P = .044). Measured by years of operation, newer nursing homes were less likely to report COVID-19 cases (OR = 0.99; P = .014). Nursing homes with a higher percentage of White residents and residents aged 65 years and older were less likely to be late reporters (OR = 0.996 (P = .05); and OR = 0.991 (P = .001), respectively). DISCUSSION Participation in data reporting requires particular information technology infrastructure and additional human and financial resources, 4 which may create barriers for smaller nursing homes. A recent study found that smaller nursing homes had a lower probability of having any COVID-19 cases, but after adjusting the size, they had a much higher outbreak size compared with nursing homes with more than 50 beds. 5 It is possible that smaller nursing homes had more COVID-19 cases adjusted by bed capacity. Therefore, they did not have additional resources to report to CMS. A similar trend was observed between chain-affiliated and freestanding nursing homes. Nonchain nursing homes may lack resources to conduct reporting, and they were more likely to have COVID-19 cases. 5 The finding of this study may signal a need to help small and nonchain nursing homes in receiving incentives or resources from CMS to overcome barriers in COVID-19 reporting. Nursing homes that operated longer in the market were more familiar with the requirement by the government in quality reporting, and they were more prepared with resources to comply with COVID-19 reporting. A study found that older adults (aged >65 years) faced a higher risk in getting COVID-19 and developing into critical conditions. 6 With more severe cases and higher death rates from older residents, especially those who are older than 65 years, nursing homes may pay more attention to COVID-19 reporting. We also spotted the racial disparity in reporting COVID-19 cases. Nursing homes with a higher percentage of minority populations were less likely to participate in reporting. Previous studies found that minority residents in nursing homes were more subject to coronavirus, which indicated a disproportionate impact of COVID-19 among different racial and ethnic groups. 5,7-9 Our study is consistent with previous findings, and CMS may need to focus on nursing homes with more minority residents and explore the underlying reasons for the disparity in COVID-19 reporting and residentsʼ cases and deaths. In conclusion, CMS successfully collected COVID-19 data from nursing homes with a wide geographical variation in participation. Additional support may be needed to help small and nonchain nursing homes to make sure they have sufficient resources to comply.
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