9 Using Home-Based Community Paramedics to Reduce Emergency Department Utilization by High-Risk Elder Patients

Abstract

Using paramedics to evaluate and treat patients in the home setting could have wide-reaching implications for patient satisfaction, health management, cost of care and patient safety in many populations, including homebound older adults. Such programs combine a comprehensive geriatric assessment by a clinician during a home visit with referrals to community providers and health plan resources to address uncovered issues. The objective was to determine the effect of a home-based community paramedicine program (HBPC) on hospital utilization by elderly patients with high acuity conditions. We sought to test the hypothesis that HBPC could significantly reduce transport to the emergency department (ED) compared to a conventional 911 system. This was a retrospective cohort analysis of elderly patients (>65 years) who triggered emergency medical services (EMS) dispatch with urgent medical calls over a 6-month study period within the Grand Rapids metropolitan area. HBPC members were compared to non-members (control group) in terms of demographics, Charlson Comorbidity Index (CCI), presenting complaints, out-of-hospital inventions, transport to the emergency department (ED), length of hospital stay (LOS) and 12-month medical costs. Chi-squared and t-tests were used to compare the two study groups across key demographic and outcome variables. During the study period, there were 3,904 EMS calls from elderly patients with high acuity conditions. The average age was 79.4 + 9.7; 57.3% were female. A total of 969 calls (24.8%) were from HBPC members; 2935 (75.2%) were controls. The two study groups were comparable in terms of demographics, acuity level, CCI scores, and insurance plans. HBPC members had a significantly greater incidence of cardiopulmonary complaints (20.3% vs 13.5%), weakness/dehydration (20.1% vs 10.1%), and abdominal pain (7.5% vs 3.7%), but fewer complaints of trauma (2.8% vs 20.6%) and altered mental status (3.8% vs 7.0%). Overall, 15.0% of HBPC members were transported to the hospital compared to 73.0% of controls (p<0.001). The mean hospital admission rate in HBPC members transported to the hospital was 38.6% with a LOS of 4.7 days. Admission rates in control patients was 59.3% with a LOS of 6.2 days (p<0.001). In 2019 dollars, the HBPC program reduced the total cost of care to the average member by $3,292 annually. Our home-based community paramedicine program was started as a solution for at-risk seniors who have difficulty navigating the health care system to get the care they need and maintaining their independence at home. These results suggest that the HBCP program significantly reduces health care costs while enabling most frail elders to avoid ED visits and prolonged hospitalization.