Curbside Consult with Dr. Jayne 1/29/24

I’m a big fan of virtual care. It has the potential to revolutionize healthcare if we can get patients, providers, payers, and state regulators all on the same page.

Unfortunately, there’s still a lot of disagreement on how reimbursement should work for the typical “outpatient” telehealth visit. Provider organizations are having to grapple with state licensure issues, especially if they are on a state border or have large numbers of patients who frequently travel away from the brick and mortar delivery site, or if they have large numbers of patients who live elsewhere but travel to the facility for care. It seems like most of the research articles I read are about that method of delivery, so I’m always interested when one comes up that features a different use case for telehealth.

This week’s JAMIA featured an article that looked at community tele-paramedicine (CTP) and how it can impact patient experience and patient satisfaction when varying levels of health disparities are present in a community. When I was a medical student doing ride-along shifts with our city’s fire and rescue squads, we spent most of our time transporting patients to the emergency department even though they didn’t have truly emergent medical conditions. A fair number of patients used EMS for transportation since they felt they didn’t have other options due to economic and geographic issues.

As a future physician, I felt powerless. It seemed like there should be a way for the paramedics and emergency medical technicians to deliver a basic level of care, such as a dressing change, without transporting the patients. However, the regulations and economic realities of the time left them with limited options.

Fast forward, and now that telehealth has become just another care delivery modality, healthcare professionals who are used to first responder roles now have other options for helping patients. New York City has embraced this, using community-based teams to deliver home-based care. Although the most visible parts of the team include community paramedics who can evaluate patients and facilitate video visits with emergency physicians, the teams also include care managers who are registered nurses that have with additional training in patient education and motivational interviewing. They coordinate with patients’ primary and subspecialty care teams, social workers, and others to make sure patients get the follow up appointments or home health services that they need. The paramedics also have additional training in the management of chronic diseases and assessing patient home environments.

Given the growth of the program and its interaction with patients who are part of vulnerable populations, the authors set out to look at patient satisfaction across areas of the city that were classified into high, moderate, and low health disparity Community Health Districts. As part of another clinical trial, the patients who were selected for this study were diagnosed with heart failure. The community paramedics who were part of the program had additional training on heart failure that included both lectures and case-based learning to simulate patient visits.

The service was available for home visits seven days per week, with nurse care managers staffed five days per week. The physicians who provided coverage for the video visits all had at least five years of post-residency experience and were certified by regional EMS officials to serve as online medical control for medics.

Patients were referred to the program after either a hospital admission or an emergency visit. Referrals could be initiated by ED / inpatient / ambulatory physicians as well as social workers and care managers, and referral was triggered within the EHR. Patients were deemed ineligible if they had active substance abuse or psychiatric issues, had been discharged to another medical facility, or were unhoused. Patients, family members, or the care team could request a home visit at any time using a triage process. Patients typically remain in the program for three months, and the program has completed 5,000 home visits since 2019.

Patients received a 12-question satisfaction survey that electronically collected anonymous data after each visit. Although medics could help patients access the survey, they could not help with completion. The authors found high levels of patient satisfaction that were similar across areas with different community-level health disparities.

They also conducted a small number of qualitative interviews, which identified some differences in how valuable patients found the service.  Those in high-disparity areas made comments that aligned with improved health literacy and more engagement with the health system, where those from areas with less disparity were more likely to comment on convenience.

The article includes direct quotes from the qualitative interviews, which touches on themes that we have known have influenced healthcare for a long time: transportation, the need to have someone to check on patients between scheduled appointments, medication education and tracking, and convenience for patients who have a large number of healthcare encounters, such as dialysis patients. 

The authors note that the program used in the study is “specific to our institution and geographic location” and that results might not be generalizable to other cities. However, I would hazard a guess that any large metropolitan area could conceivably achieve similar results. They also noted that the specific design around a heart failure diagnosis may create issues with trying to generalize performance to other chronic conditions. I would also guess here that other chronic conditions such as pulmonary disease, kidney disease, or diabetes may yield similar outcomes. However, we won’t know for sure unless we study other conditions in other geographies.

I’m hoping that other institutions might see this publication and consider conducting research on their own populations, or seeking funding for similar programs that might tell us more about healthcare in rural or other underserved areas.

Additionally, if you couple studies about these kinds of programs with cost savings data, we can build a stronger case about why telehealth provides good value in an environment where healthcare spending is constantly on the rise. We can also couple it with outcomes data to identify cases where care is not only equivalent to in-person care, but where it might actually be better. I think that if we fast-forward another five years, we will be able to make a lot stronger conclusions than we can make today.

Is your organization considering a community paramedic program or does it already have one in place? Leave a comment or email me.

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