Can the Introduction of an Integrated Service Model to an Existing Comprehensive Palliative Care Service Impact Emergency Department Visits among Enrolled Patients?

Abstract

Purpose-Fewer emergency department (ED) visits may be a potential indicator of quality of care during the end of life. Receipt of palliative care, such as that offered by the adult Palliative Care Service (PCS) in Halifax, Nova Scotia, is associated with reduced ED visits. In June 2004, an integrated service model was introduced into the Halifax PCS with the objective of improving outcomes and enhancing care provider coordination and communication. The purpose of this study was to explore temporal trends in ED visits among PCS patients before and after integrated service model implementation.Methods-PCS and ED visit data were utilized in this secondary data analysis. Subjects included all adult patients enrolled in the Halifax PCS between January 1, 1999 and December 31, 2005, who had died during this period (N = 3221). Temporal trends in ED utilization were evaluated dichotomously as preintegration or postintegration of the new service model and across 6-month time blocks. Adjustments for patient characteristics were performed using multivariate logistic regression.Results-Fewer patients (29%) made at least one ED visit postintegration compared to the preintegration time period (36%, p < 0.001). Following adjustments, PCS patients enrolled postintegration were 20% less likely to have made at least one ED visit than those enrolled preintegration (adjusted OR 0.8; 95% confidence interval 0.6-1.0).Conclusion-There is some evidence to suggest the introduction of the integrated service model has resulted in a decline in ED visits among PCS patients. Further research is needed to evaluate whether the observed reduction persists.

Health Care Utilization by Patients Whose Care Is Managed by a Primary Palliative Care Clinic

“…3,6,10,11,14 The findings also demonstrate that combined outpatient primary and palliative care decrease ED utilization and hospital admissions in patients with life limiting illness. Given the imminent changes to the United States healthcare system, including the establishment of accountablecare organizations charged with reducing ED utilization and hospital admissions, the dissemination of this study could have a significant impact on decreasing unnecessary healthcare utilization across the country.…”

“…13 EDs tend to be high stress, fast paced environments with a focus on treatment of acute and traumatic events, 14 and are not the ideal place to treat palliative care patients or those nearing the end of life. 13,14 For example, privacy in the ED is limited, staff members are often not familiar with patients, nor are they necessarily trained to deal with many issues associated with the end of life. 14 Further, patients and their caregivers experience high levels of anxiety and uncertainty when accessing the ED.…”

“…12 Researchers identified several determinants of ED use among their palliative care population including excessive weight loss, a previous hospitalization, 2 women residing in rural areas, having a parent or other relative other than a spouse or child as the primary caregiver, 3 pain, and appetite disturbance. 13 EDs tend to be high stress, fast paced environments with a focus on treatment of acute and traumatic events, 14 and are not the ideal place to treat palliative care patients or those nearing the end of life. 13,14 For example, privacy in the ED is limited, staff members are often not familiar with patients, nor are they necessarily trained to deal with many issues associated with the end of life.…”

“…13,14 For example, privacy in the ED is limited, staff members are often not familiar with patients, nor are they necessarily trained to deal with many issues associated with the end of life. 14 Further, patients and their caregivers experience high levels of anxiety and uncertainty when accessing the ED.…”

“…For example, palliative care programs have been associated with a reduction in the number of ED visits made by enrolled patients. [13][14][15][16] To illustrate this, in a pilot study by Owens et al (2012) outpatient primary palliative care patients' mean number of ED visits per week decreased from almost 0.07 visits per week in the earlier period to 0.04 visits per week after enrollment. 13 Outpatient palliative care is relatively new, and there are limited studies validating its benefits.…”