Abstract
BackgroundThe management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices.Methods and findingsAn interrupted time series design and qualitative interviews were used to evaluate a multifaceted intervention, SCOPE (Seamless Care Optimizing the Patient Experience), offered to solo PCPs whose patients were frequent users of the ED. The intervention featured a navigation hub (nurse, homecare coordinator) to link PCPs with hospital and community resources, a general internist on-call to provide phone advice or urgent assessments, and access to patient results on-line. Continuous quality improvement (QI) strategies were employed to optimize each component of the intervention. The primary outcome was the relative pre-post intervention change in ED visit rate for patients of participating practices compared with that for a propensity-matched control group of physicians over the contemporaneous period. Themes were identified from semi-structured interviews on PCP’s experiences and influential factors in their engagement. Twenty-nine physicians agreed to participate and were provided access to the intervention over an 18-month time period. There were a total of 1,525 intervention contacts over the 18-months (average: 50.6±60.8 per PCP). Both intervention and control groups experienced a trend towards lower rates of ED use by their patients over the study time period. The pre-post difference in trend for the intervention group compared to the controls was not significant at 1.4% per year (RR = 1.014; p = 0.59). Several themes were identified from qualitative interviews including: PCPs felt better supported in the care of their patients; they experienced a greater sense of community, and; they were better able to provide shared primary-specialty care.ConclusionsThis multifaceted intervention to support solo PCPs in the management of their complex patients did not result in a reduced rate of ED visits compared to controls, likely related to variable uptake among PCPs. It did however result in more comprehensive and coordinated care for their patients. Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs.
Highlights
An aging population and medical progress have led to increasing numbers of people living with one or more chronic conditions [1,2,3,4,5], who are at increased risk for emergency department (ED) visits, and hospital admissions [6,7,8]
The other authors declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials. This multifaceted intervention to support solo primary care providers (PCPs) in the management of their complex patients did not result in a reduced rate of Emergency Department (ED) visits compared to controls, likely related to variable uptake among PCPs
Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs
Summary
The Nuka System of Care model in Southcentral Alaska, created comprehensive team-based primary care to support the local community, with specialist consultation brought into the team as needed [14] This model has been associated with improved health outcomes and a decrease in healthcare utilization [15]. The CareMore Model, which provides primary care by interdisciplinary teams with support from internists during hospitalizations and periods of health deterioration, achieved lower hospitalization rates and inpatient length of stay compared to the Medicare average [16]. These models support enhancing primary care through interdisciplinary teams with access to more acute care support.
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