Patients with complex physical, behavioral, and social needs present unique challenges to the health care system, including disproportionately high costs. These patients are often sick, immobile, and alone. Their experiences in the health care system are fragmented and inadequate, and traditional clinic-based primary care pathways, with care being delivered in 15-minute increments or shorter, do not represent an effective way to contend with the significant medical, behavioral health, and social complexities that these individuals face. Mistrust pervades, and engagement is limited. Although new paradigms such as the patient-centered medical home have encouraged the integration of services, they have overlooked a crucial fact: namely, that we remain focused on where clinicians conduct their business rather than on where our patients live. In so doing, we have perpetuated systems of care that overly burden patients, unnecessarily exposing them to the risk of nosocomial infections, devaluing their time, and creating barriers to full access for those in the greatest need of dedicated and timely attention.
As health care has consolidated and centralized into institutional settings, we have lost the intimacy and patient-centered engagement of the traditional home-based delivery models that defined early modern medicine. In this evolution toward a concept of the health facility as the presumed nexus of care delivery, we have lost the ability to effectively engage individuals with the most complex needs in tailored and respectful systems of care. To build a true culture of health care for complex populations, we must seek to enhance the ability of our delivery systems to care for patients in settings of their choice with use of tools that are both customized and flexible. Our system must become a primary care–driven model enhanced by innovative tools such as community medicine and telehealth, which, taken together, can meet patients in their most comfortable environment: the place they call home.
Mobile Integrated Health/Community Paramedicine: A Solution with Great Potential
Ample evidence demonstrates that the high rate of misuse of emergency departments (EDs) is the result of critical access gaps and is a major cause of excess spending. Mobile integrated health care and community paramedicine (MIH/CP) programs are an emerging high-value tool that can be used to close access gaps and to facilitate cost-effective care that can be provided on patients’ terms in home or community settings. These programs take many forms, but they all seek to address critical gaps in community delivery systems, including insufficient primary care, inadequate behavioral health supports, and fragmented emergency and urgent care networks. In MIH/CP programs, the role of emergency medical services personnel (either paramedics or emergency medical technicians) is expanded to encompass rapid-response outpatient urgent and primary care, mitigating the need for hospital-based services. A unifying feature of these models is a focus on providing necessary clinical services in the community, thereby avoiding the need for the patient to travel (or to be transported) to the clinic or hospital to receive care.
The scope of opportunity for MIH/CP programs to serve as a substitute for ED visits is astronomical; it has been reported that 14% to 27% of all ED visits in the United States could be handled in a primary care, urgent care, or retail clinical setting, for savings of $4.4 billion annually. MIH/CP programs have proliferated in recent years, spurred by rising health care costs, overcrowding in EDs, and widespread interest in shifting care away from more expensive institutional settings and toward community settings. Yet, despite increasing recognition of the potential for MIH/CP programs, rigorous research evaluating their effectiveness is significantly lacking.
Commonwealth Care Alliance’s Acute Community Care Program
Recognizing that MIH/CP programs afford at-risk delivery systems and integrated providers the opportunity to optimize care in low-intensity community-based settings, Commonwealth Care Alliance (CCA), a Massachusetts-based nonprofit integrated delivery system, launched a MIH/CP pilot program in 2013. CCA is a hybrid payer-provider for beneficiaries who are dually eligible for Medicare and Medicaid. Its members have extreme medical, behavioral health, and social needs and use ED services at a rate that is >300% higher than that for the general population in Massachusetts. CCA’s MIH/CP program, known as Acute Community Care (ACC), was designed to address the significant need for high-quality, timely, and person-centered acute care as well as to identify a cost-effective alternative to the ED for this high-risk population.
In CCA’s model, ACC paramedics with specialized training and diagnostic and therapeutic capabilities visit patients in their homes to provide assessment and treatment and concurrently communicate with primary care teams. The paramedics are trained to care for patients with complex clinical and psychosocial complaints, ranging from acute decompensated COPD to anxiety, heart failure, and urinary tract infection. They are equipped with rapid bedside diagnostic tools, have access to the patient’s primary electronic medical record, and collaborate in real time with on-call physicians and advanced practice clinicians.
Early Results of the ACC Program
In the first year of operations, 81% of patients who received an ACC visit remained at home under the care of ACC paramedics with CCA clinical follow-up, whereas 19% were transported to an ED within 7 days after an ACC visit. Additional clinical outcomes and preliminary patient-satisfaction metrics have been published elsewhere and are currently undergoing extensive investigation as part of a multi-year Patient-Centered Outcomes Research Institute study.
To further evaluate the cost impact of this program, CCA commissioned a rigorous study comparing the claims experience of ACC patients with those of three propensity score-matched cohorts of CCA members from different regions of Massachusetts. To mirror capitated incentives, the unit of analysis was an episode of care beginning with a visit by an ACC paramedic (or an ED visit for comparison patients) and subsequent claims for ambulance use, ED visits, hospital observation stays, and inpatient admissions.
The CCA study demonstrated that patients who received care in their homes through the ACC program had lower average costs than comparison patients who received care in the ED (per-patient, per-episode savings: $791 at 7 days after the index event, $3,677 at 15 days, and $538 at 30 days). For the 980 members who were served in the first year of the program, CCA achieved net savings of $454,720 ($464 per member per episode). CCA members significantly preferred ACC visits to ED transports; 85% of ACC-treated patients reported that the program prevented an ED trip, and 95% affirmed that the quality of an ACC visit was comparable to or better than that of an ED visit.
Opportunities for Greater Success and Scale
The flexibility of this care model facilitates adaptation to the varied needs of diverse community environments, creating a crucial access point to engage patients in effective care outside of institutional settings, especially as public-payer accountable care organizations (ACOs) continue to emerge. In particular, given the significant evidence regarding the lack of urgent care and retail clinics in low-income communities, ACC offers a rapidly scalable model to leverage available community-based resources and provides a nimble, mobile deployment model to meet community needs, with a workforce that is accustomed and eager to work in resource-poor environments.
The CCA study identified three key drivers of savings that are relevant for scaling ACC-like programs:
- Patient volume is a powerful driver of ACC savings because of the spread of fixed costs, with a 10% increase in patient volume yielding an 18% increase in expected savings.
- The ED diversion rate is also a key driver of savings, with a 2.5% increase in the average ED diversion rate leading to a 5% increase in expected savings. MIH/CP programs can increase diversion rates through more accurate triage or by increasing the services that community paramedics can provide on site.
- Operating costs for the ACC program itself are a third primary driver of savings, with a 10% increase in operating costs decreasing savings by 8%. Managing fixed costs by leveraging operational efficiencies as programs scale could significantly impact overall savings.
Taken together, these three primary drivers shine a crucial light on opportunities to expand MIH/CP programs to meet the pressing need for cost-effective (i.e., primarily home-based and community-based) alternative models of care delivery. Evidence from the CCA’s ACC experience suggests that MIH/CP programs can deliver high-quality, patient-centered care at a lower cost than the traditional ED-based approach while also achieving a second core aim of delivery system transformation — namely, returning care into patients’ homes.
We believe that this disruptive care model has huge potential to enhance the care experience of patients with complex needs and to deliver higher value to the health care systems that serve them. Providers can use MIH/CP programs together with other emerging innovations such as telehealth to break down barriers to care by interrupting the power dynamics, time limitations, and access issues that an office or facility setting presents. Moreover, payment reforms that center on capitated payments will offer ample opportunity to sustain and expand this care model because of the substantial potential for savings. We believe that true integration of patient-centered clinical care with social supports, delivered in the home, has the potential to transform our ability to help our most vulnerable patients and must be at the forefront of our efforts to transform delivery and payment systems.