Bringing It Home: The Shift in Where Health Care Is Delivered | Emergency Medicine | JAMA Forum Archive | JAMA Network
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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Bringing It Home: The Shift in Where Health Care Is Delivered

Many health care organizations give little more than lip service to becoming “patient-centered.” Perhaps it’s because our legal and regulatory environments preclude true system transformation that focuses on what patients need and want. But laws and regulations are changing, albeit slowly, and we are shifting to value-based payment methodologies that reward improved outcomes and lowered costs.

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Consider the example of an elderly woman with multiple sclerosis and dementia who was cared for by her husband of 50 years. Getting around was challenging for her and she fell repeatedly. Dressing for a medical appointment could take up to an hour, trips in and out of the car were a chore, and multiple health care environments increased her confusion. Her husband, too, was becoming increasingly exhausted, as each change in her condition often required visits to several physicians in various settings. Each time she fell, he called 911 and paramedics helped her up, but because they weren’t allowed to treat her at home, they transported her to the emergency department (ED), where the bright lights, loud noises, and long waits would exacerbate her agitation and cause additional stress to her and her husband.

The reason she was transported to the ED is that under Medicare and most insurance policies, the paramedics’ visit is not otherwise reimbursed. In addition, some states have laws that limit what paramedics and emergency medical technicians (EMTs) can do in a patient’s home.

This example illustrates an opportunity to improve health care workers’ flexibility in responding to the needs of patients and their families. Currently, an enhanced focus on complex care for people with complex health and social needs who cycle in and out of the ED and have frequent hospital stays—the 5% of the people who account for 50% of health care spending—is driving changes that will likely transform how we think about where care is delivered and by whom.

Ready Responders

In Louisiana, for example, a new service named Ready Responders allows patients and their families to quickly request health care in their homes through the use of an app—much like an Uber app—that connects them to an on-demand network of nurses, EMTs, and paramedics. They also follow patients with complex health and social needs in their homes to prevent emergencies and hospitalizations. Anne Montera, RN, senior vice president for quality at Ready Responders, explains that on assessment, patients who need to be treated at the ED are transferred there but those who can be treated at home remain, thus avoiding unnecessary use of the ED and potential hospitalization. “We’re also seeing patients where they live,” she adds, “along with the condition of their home, its safety, and whether they have enough food.”

Currently organized as part of a medical group practice and practicing under the auspices of a physician, the EMTs and paramedics, along with Ready Responders’ nurses, also make sure that patients are connected to a primary care clinician and address social determinants of health as needed. To set priorities for care, they discuss with patients and their families the health-related issues that are most important to them.

New Policy and Funding Changes Affecting Care Delivery

What measures could help Ready Responders to expand beyond Louisiana and encourage other similar initiatives?

Montera notes that her company is looking to build in its quality measures and operate according to a pay-for-performance system. Her colleague, Victoria Sale, RN, senior vice president for patient and community care development, adds that Ready Responders has reduced nonacute visits to the ED in the largest health system in New Orleans by 70%. For high utilizers, she says, ED use was lessened by more than 65%. Instead of making payment dependent on an ED visit when value-based payment is not available, paramedics can “treat at the scene” and bill under two reimbursement codes: “mobile urgent care/telehealth” and “weekly scheduled home visits.”

Evidence suggests that shifting to value-based reimbursement—such as rewarding paramedics for transporting patients to primary care instead of the ED—could lead to a potential savings of $560 million per year. In addition, emergency medical services (EMS) pilot programs are building the case for integrated teams and telehealth-enabled services. In one study of 5570 patients in Houston, researchers used telehealth services, social services, and alternative transportation to navigate patients away from the ED and toward primary care settings whenever possible. As a result, ambulance transports to the ED decreased by 56%, and EMS productivity (defined as “back in service”—the time from dispatch of the EMS team to being available to be dispatched again) was improved by 44 minutes.

Such outcomes are prompting the Centers for Medicare & Medicaid Services (CMS) to incentivize treating patients in the least expensive setting. This summer, CMS is launching a request for applications for the Emergency Triage, Treat and Transport (ET3) initiative, a 5-year project slated to begin in January 2020. Under this payment model, ambulance care teams will have flexibility in providing care to Medicare beneficiaries, including the ability to (1) evaluate and transport a patient directly to primary care or urgent care or to (2) evaluate and treat the patient on the scene with the support of a qualified health care professional, in person or through telehealth.

By encouraging a partnership between EMTs and entities that manage 911 services, the initiative will allow for an initial triage to lower acuity or provide more appropriate care prior to ambulance dispatch. Once on the scene, ambulance providers will be paid to triage, treat, and transport patients to the most appropriate settings, including urgent care, primary care, or care in the home. The purpose of the initiative is to incentivize care provision at the right time and place, encourage appropriate use of emergency services, and expand EMS providers’ capacity to respond to such actual emergencies as heart attacks and strokes.

Another program designed to incentivize care in the home, reduce inpatient hospitalizations, and decrease fee-for-service charges is CMS’ Primary Care First, which includes a set of 5 new primary care payment demonstration models planned to go into effect in January 2020. Focused on primary care practices, the demonstrations offer a range of options to shift to global payments, including a flat per-patient rate to decrease administrative costs and the opportunity to receive quarterly revenue based on quality outcomes performance. In these new payment models, keeping patients healthy, stable, and at home is key to success. The intent is to remove administrative barriers for practitioners and incentivize population management, thus encouraging collaboration across settings and disciplines. Nurse-delivered models such as Health Quality Partners’ Advance Preventive Care have already demonstrated the effect of bringing proactive care into the home, resulting in reduced mortality, 33% fewer hospitalizations, and a 22% reduction in cost. But to spread such innovations, outdated, restrictive aspects of the Medicare law regarding home care must change.

Regulatory and legal changes to support innovations in care delivery can’t come soon enough. The effort required to realize these changes is inconsequential compared with the potential gains: time saved, lowered costs, reduced stress, and the ability to offer patients what they want most—receiving appropriate care in the comfort of their own homes, where they will no longer have to contend with the hassles of an outdated health care system.

About the Authors:
Lauran Hardin, MSN, RN, is the senior director of education and curriculum  for the Camden Coalition’s National Center for Complex Health and Social Needs. She codesigns models and develops curricula for the field of complex care. She serves on the advisory group for The Playbook: Better Care for People with Complex Needs, led by the Institute for Healthcare Improvement and the Center for Health Care Strategies, and is vice president of networks and partnerships for the National Academies of Practice. (Image: Terry Johnston Photography)
Diana J. Mason, PhD, RN, is senior policy service professor at George Washington University School of Nursing’s Center for Health Policy and Media Engagement and professor emerita at Hunter College, City University of New York. She currently serves as a member of the board of directors of Public Health Solutions and the Primary Care Development Corporation. She is a former president of the American Academy of Nursing. (Image: Ted Grudzinski/AMA)
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