The U.S. healthcare system has consistently struggled with inefficiencies in Emergency Department (ED) usage (Enard & Ganelin, 2013). Frequent ED users comprised “4.5% to 8% of all ED patients but account for 21% to 28% of all visits” (LaCalle, 2010). Furthermore, 13% to 27% of ED visits in the United States could be managed in primary care settings, with an estimated savings of $4.4 billion annually (Weinick, et al., 2010). Many of these individuals suffer from preventable health issues that could be resolved through early intervention and health education (Dowd, et al., 2014).
ED visit reduction programs vary widely in strategy, provider composition, and effectiveness (Raven, 2016). Recent evidence has indicated that programs focused on providing post-acute care coordination for frequent utilizers of ED services may not be effective in reducing overall hospital utilization (Finkelstein, 2020). In order to identify effective methods for reducing visits from frequent ED users, a local community paramedicine program focusing on providing support for social determinants was selected to evaluate and study. While community paramedicine programs have been evaluated in the past (Bigham, 2013), very few programs have focused their intervention specifically on social determinants. By evaluating a locally supported, currently functioning, and unique adaptation of ED visit reduction programs, this study has the potential to help inform health care delivery improvement efforts throughout the U.S.
As communities have searched for innovative strategies to break the cycle of poor health and high demand on community services, the community paramedicine (CP) model has emerged nationwide as a promising evidence-based approach (O’Meara 2014). The CP model seeks to improve health outcomes, system costs, patient quality, and utilization efficiency within established emergency medical services (EMS) infrastructure (Gregg, 2019). In CP programs, Fire Rescue or EMS departments utilize front-line paramedics in collaboration with interdisciplinary partners such as physicians and social workers to address the needs of these vulnerable patients with complex medical and social needs. The CP model has been successful outside the U.S. for some time (Snooks, 1998) and has been recently adapted to address specific inequity and inefficiency issues particular to the U.S. healthcare system (Iezzoni, 2016). CP and other types of mobile integrated health care (MIH) programs have been effective in reducing frequent ED utilization (Nejtek, 2017), improving chronic disease measures (Bennett, 2018), generating savings by partnering with payer and provider networks (Roeper, 2018), and assisting primary care physicians with care coordination (Chellappa, 2018).
The Gainesville Community Resource Paramedic Program
In 2017, over 189 Gainesville residents called 911 more than five times in one year, and thirty-nine of those patients called 911 more than ten times in one calendar year. In order to address these needs, the Gainesville Community Resource Paramedic Program (Gainesville CRP) was established in 2017. Gainesville CRP is a collaboration between University of Florida Health (UF-Health) and Gainesville Fire Rescue (GFR) designed to support patients with complex health and social support needs in Alachua County and reduce ED visits at UF-Health Shands Hospital (Shands).
The Gainesville Community Resource Paramedicine (CRP) program was created by Gainesville Fire Rescue in search of a new paradigm for delivering emergency medical services. In this model, a paramedic and resource coordinator utilize a non-fire apparatus and visit patients in their homes following a referral for frequent use of ED services. The focus of the program is to address social determinants of health and resolve underlying issues of frequent ED utilization. Gainesville CRP personnel comprehensively evaluate and directly address social needs of patients including food security, transportation, employment, and disability access. Furthermore, Gainesville CRP personnel communicate with healthcare providers in real-time to ensure patients are adhering to their medication and treatment plans, convey details of their complete social picture, while also conducting detailed wellness checks on patients of particularly high-risk. These interactions last for a minimum of six months and services are provided directly in a patient’s home. Gainesville CRP coordinates with and is overseen by UF-Health family practice physicians.
While CP and ED visit reduction programs are not new (Thompson, 1991), the use of CP to connect patients to existing community resources not traditionally provided by health systems while also working alongside an established PCP is unique (Siddle, 2018). Most other previously studied ED reduction programs offered only case management and care coordination until the patient could be established in primary care. Previous research has indicated that frequent ED users are “as likely as infrequent users to have a usual source of care” (Cunningham, 2017) and that other research has shown that these patients “do not believe” that PCPs can provide non-medical but health related support (Enard, 2017). Gainesville CRP is designed to provide a resource focused and community embedded intervention that can improve social determinants of health that PCPs or acute care facilities cannot address. This unique approach represents a significantly more involved intervention than many other “complex care” or “hot-spotting programs” programs (Iovan, 2020) currently in the literature.
The goal of this coordinated effort is to reduce avoidable hospital visits and 911 calls as well as improve the quality of life of those served by the program. After its first two years of implementation, the Gainesville CRP program has become a nexus in Alachua County connecting patients to social and medical services while fostering relationships ensuring a safety net for self-management of chronic disease (Caplan, 2019).
In order to evaluate the initial implementation of Gainesville CRP, surveying existing literature is necessary to place the current program in context. While Gainesville CRP is founded on a CP model, the focus on social determinants and community support services places Gainesville CRP as a unique adaptation of the CP model. Identifying the ways in which this kind of intervention is similar or different to existing studies will provide context for the effective components of the program. Also, since the program has already been implemented and does not have a randomization process or a prospective evaluation strategy, understanding the evidence from the pilot in context of study design limitations is needed. Finally, this study should setup a more thorough randomized control trial (RCT) or prospective cohort (PC) in the future that reflects the needs of current literature in the field.
Misconceptions in Emergency Department Utilization
There is a common assumption that frequent use of the Emergency Department is the result of indigent or underinsured patients who wish to access free sources of care in emergency settings rather than access care through a primary care provider. This assumption also holds that many of these visits are low-acuity, non-emergent, and would be most appropriately handled in a primary or secondary care office. The framework in Figure 1 illustrates the nature of this assumption:
In this model, indigent patients with a history of cost avoidance in health care consumption are subsequently not established in primary care. When need for care is presented, this pattern will lead to ED visits out of concern for cost and a lack of other available options. This is contrasted with non-indigent patients that are insured, established in primary care, and expect to participate in cost sharing as a responsible consumer of health care services. When need for care arises, they will consult with a primary care physician rather than visit an ED. Under this framework, the interventions that would seek to alleviate the inappropriate use of EDs would seek to establish indigent patients in primary care so that future care needs could be addressed in more appropriate spaces.
Unfortunately, this framework does not adequately explain the demographics of frequent ED users and their reasons for visiting the ED. Frequent ED users tend to have established PCPs (Zhou, 2013), health insurance coverage (Zhou, 2017), utilize care at higher rates in both ED and non-ED settings including PCP visits (Giannochous 2019), are between the ages of nineteen and forty-four (Giannochous 2019), visit the ED for exacerbations of common chronic diseases (Vinton, 2013), have lower self-reported health status (Vinton, 2013), and utilize the ED for services that PCPs are unable to deliver (LeCalle, 2010). This indicates that the frequent ED user is not primarily utilizing out of a lack of establishment in a PCP, but instead has a higher level of complexity in chronic disease that requires extra care outside of services that a PCP can offer. Similarly, food insecurity was identified in a number of studies as a significant predictor of frequent ED use (Giannochous, 2019) suggesting that social determinants may play an outsized role in predicting exacerbated health needs requiring an ED visit for this population. From this perspective, interventions that focus on case management or care coordination will not be able to address the underlying lack of services that would be necessary to reduce utilization. These approaches would only connect patients to services that they already may be utilizing at higher levels. Instead, interventions would need to identify the components of chronic disease care that are not being provided to patients as well as the social determinants that are not being addressed by existing care services.
In a survey of frequent Emergency Department utilizers, LeCalle writes:
“First, the data from these studies challenge the common assumption that frequent ED use is a problem of uninsured, ethnic minority patients inappropriately seeking basic primary care in the ED… Furthermore, much of the frequent ED use is not for primary care. Although some patients certainly use the ED multiple times for low-acuity complaints, the consensus in the literature is that frequent users often are sick patients with chronic illness associated with high admission rates and high mortality." (2010)
While studies like this one have established the discrepancy between assumptions and reality in the context of ED use, almost all programs that sought to alleviate frequent ED utilization focused on care coordination or case management (Raven, 2016). In a more recent review, studies that only included care coordination showed none or mixed results (Iovan, 2020). In a scoping review of studies in CP, only four of the eight identified studies included social support services outside of healthcare and none were specifically focused on providing care that meaningfully addressed social determinants (Gregg, 2019). While comprehensive improvements to primary care delivery emerging alongside value-based payment programs may help in improving frequent ED usage, CP has the potential to help address upstream needs while integrating seamlessly into current health care delivery.
The Need for More Robust Methodology
When evaluating the current data from the pilot CRP program, a method needed to be developed that can account for ED use independent of PCP visits before and after enrollment. Similarly, this method must be able to identify evidence that can also account for possible “reversion to the mean” that occurs as a result of a natural drop in overall utilization. Of the studies that utilized observational data for CP interventions, no studies attempted to account for either of these contexts.
There is also a significant need for CP studies that utilize a PC or RCT design to be published in order to advance the implementation of CP throughout the U.S. Recent evidence from the Camden Coalition (Finkelstien, 2019), indicates that when random assignment is used to control for biases in evaluating ED diversion programs, a significant “reversion to the mean” is observed. In a review of ED reduction programs, authors noted that “methodological and study design weaknesses -especially regression to the mean- were widespread and call into question reported positive findings” (Iovan, 2020). Based on the existing literature, observational; study design methods need to be developed that can account for the above limitations and provide robust evidence for future PC or RCT studies.