Video or Telephone? A Natural Experiment on the Added Value of Video Communication in Community Paramedic Responses.

STUDY OBJECTIVE: The objective of this study was to determine the effect of video versus telephonic communication between community paramedics and online medical control physicians on odds of patient transport to a hospital emergency department (ED). METHODS: This was a retrospective analysis of data from a telemedicine-capable community paramedicine program operating within an advanced illness management program that provides home-based primary care to approximately 2,000 housebound patients per year who have advanced medical illness, multiple chronic conditions, activities of daily living dependencies, and past-year hospitalizations. Primary outcome was difference in odds of ED transport between community paramedicine responses with video communication versus those with telephonic communication. Secondary outcomes were physicians' perception of whether video enhanced clinical evaluation and whether perceived enhancement affected ED transport. RESULTS: Of 1,707 community paramedicine responses between 2015 and 2017, 899 (53%) successfully used video; 808 (47%) used telephonic communication. Overall, 290 patients (17%) were transported to a hospital ED. In the adjusted regression model, video availability was not associated with a significant difference in the odds of ED transport (odds ratio 0.80; 95% confidence interval 0.62 to 1.03). Online medical control physicians reported that video enhanced clinical evaluation 85% of the time, but this perception was not associated with odds of ED transport. CONCLUSION: We found support that video is considered an enhancement by physicians overseeing a community paramedicine response, but is not associated with a statistically significant difference in transport to the ED compared with telephonic communication in this nonrandom sample. These results have implications for new models of out-of-hospital care that allow patients to be evaluated and treated in the home.

Physician clinical management strategies and reasoning: a cross-sectional survey using clinical vignettes of eight common medical admissions.

BACKGROUND: Physicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions. METHODS: We conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections. RESULTS: Our sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies "always" or "most of the time" when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies. CONCLUSIONS: For eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

Care Team Perspectives and Acceptance of Telehealth in Scaling a Home-Based Primary Care Program: Qualitative Study.

BACKGROUND: Novel and sustainable approaches to optimizing home-based primary care (HBPC) programs are needed to meet the medical needs of a growing number of homebound older adults in the United States. Telehealth may be a viable option for scaling HBPC programs. OBJECTIVE: The purpose of this qualitative study was to gain insight into the perspectives of HBPC staff regarding adopting telehealth technology to increase the reach of HBPC to more homebound patients. METHODS: We collected qualitative data from HBPC staff (ie, physicians, registered nurses, nurse practitioners, care managers, social workers, and medical coordinators) at a practice in the New York metropolitan area through 16 semistructured interviews and three focus groups. Data were analyzed thematically using the template analysis approach with Self-Determination Theory concepts (ie, relatedness, competence, and autonomy) as an analytical lens. RESULTS: Four broad themes-pros and cons of scaling, technology impact on staff autonomy, technology impact on competence in providing care, and technology impact on the patient-caregiver-provider relationship-and multiple second-level themes emerged from the analysis. Staff acknowledged the need to scale the program without diminishing effective patient-centered care. Participants perceived alerts generated from patients and caregivers using telehealth as potentially increasing burden and necessitating a rapid response from an already busy staff while increasing ambiguity. However, they also noted that telehealth could increase efficiency and enable more informed care provision. Telehealth could enhance the patient-provider relationship by enabling caregivers to be an integral part of the patient's care team. Staff members raised the concern that patients or caregivers might unnecessarily overutilize the technology, and that some home visits are more appropriate in person rather than via telehealth. CONCLUSIONS: These findings suggest the importance of considering the perspectives of medical professionals regarding telehealth adoption. A proactive approach exploring the benefits and concerns professionals perceive in the adoption of health technology within the HBPC program will hopefully facilitate the optimal integration of telehealth innovations.

Brief communication: National quality-of-care standards in home-based primary care.

BACKGROUND: Home-based primary care for homebound seniors is complex, and practice constraints are unique. No quality-of-care standards exist. OBJECTIVE: To identify process quality indicators that are essential to high-quality, home-based primary care. DESIGN: An expert development panel reviewed established and new quality indicators for applicability to home-based primary care. A separate national evaluation panel used a modified Delphi process to rate the validity and importance of the potential quality indicators. PARTICIPANTS: Two national panels whose members varied in practice type, location, and setting. RESULTS: The panels considered 260 quality indicators and endorsed 200 quality indicators that cover 23 geriatric conditions. Twenty-one (10.5%) quality indicators were newly created, 52 (26%) were modified, and 127 (63.5%) were unchanged. The quality indicators have decreased emphasis on interventions and have placed greater emphasis on quality of life. LIMITATIONS: The quality indicator set may not apply to all homebound seniors and might be difficult to implement for a typical home-based primary care program. CONCLUSIONS: The quality indicator set provides a comprehensive home-based primary care quality framework and will allow for future comparative research. Provision of these evidence-based measures could improve patient quality of life and longevity.

"It's Really Overwhelming": Patient Perspectives on Care Coordination.

PURPOSE: Failures of care coordination among health care providers are known to lead to poorer health outcomes for patients with complex medical needs. However, there has been limited research into the perspectives of patients who receive care from a variety of health care providers. This qualitative study sought to characterize the factors leading to emergency department (ED) patient satisfaction and dissatisfaction with their care coordination. METHODS: Semistructured telephone interviews were conducted with 25 adult patients following ED visits about their experiences with their care coordination. All patients interviewed had 2 or more ED visits and hospitalizations in the past year and/or health providers in more than one health system. Interview transcripts were coded and analyzed following a modified grounded theory approach. RESULTS: Four broad categories of themes emerged from the patient interviews covering the following: (1) perceptions of care coordination between their providers, (2) the role of electronic health records, (3) challenges with information exchange between health systems, and (4) sources of support for care coordination activities, emphasizing the important role of the primary care provider. CONCLUSIONS: Patients with multiple health care providers identified significant barriers to communication among providers and inadequate support with care coordination activities. Expansion of team-based models of primary care and prioritizing interoperable technology for sharing patient health information between providers will be critical to improving the patient experience and the safety of transitions of care.

Training Tomorrow's Teachers Today: a national medical student teaching and leadership retreat.

INTRODUCTION: Challenges to American academic medical centers have diverted attention and resources away from the core missions of teacher and leader development. To train the next generation of medical education leaders, substantial and institutionalized new programs are necessary. METHODS: The American Medical Student Association, with the Mount Sinai School of Medicine, designed the Training Tomorrow's Teachers Today national medical student retreat. The week-long course endeavors to enhance participants' clinical teaching and academic leadership skills. The program also trains students to execute a required medical education project. At the end of the course, attendees evaluated their baseline and post-course teaching and leadership effectiveness. Long-term follow-up was also completed. RESULTS: Attendees (n = 23) self-reported statistically significant (p < 0.05) improvement in teaching and leadership. The greatest improvements in teaching scores were in the area of communicating goals. The largest leadership score improvements were: defining goals; defining constituents, allies, and opponents; and delineating organization strengths/weaknesses. 13 participants engaged in medical education projects. CONCLUSION: This program helps fill a gap in medical education training. Program data suggest enhancement of students' teaching and leadership skills. A competitive application process demonstrates interest in such training. These results suggest that medical schools should offer and/or fund undergraduate teaching and leadership training.

A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward.

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.

The use of the mini-mental state examination in recruitment for substance abuse research studies.

BACKGROUND: Substance abuse is associated with cognitive impairment. Participation in clinical addiction research can be cognitively demanding. Screening tools can identify cognitively impaired subjects. We examined the use of the mini-mental state examination (MMSE) as an entry criterion in three randomized controlled substance abuse clinical trials. METHODS: In each of the three studies, we calculated the proportion of subjects excluded due to MMSE scores (<21) suggestive of cognitive impairment. We estimated the potential impact on enrollment based on the number of excluded subjects. Separately, for two of the studies, we assessed the impact of cognitive function on participation in follow-up using multivariable logistic regression. RESULTS: Of all persons screened for enrollment, 1.6% (171/10,791) were ineligible based solely on a MMSE score of <21. We estimate that 119 of these 171 ineligible persons would have consented and enrolled. These 119 persons would have represented 9.3% of all enrolled subjects across these studies. For subjects in a study in an inpatient detoxification unit, a higher MMSE score was associated with higher odds (adjusted odds ratio 1.15, 95% CI 1.03-1.30) of completing at least one follow-up assessment. A similar impact on subject follow-up was not observed in a study of medical inpatients with unhealthy alcohol use (adjusted odds ratio 1.01, 95% CI 0.86-1.20). CONCLUSION: Screening for cognitive impairment using the MMSE excludes a small, but substantial, number of persons from addiction research studies. Cognitive ability, as captured by the MMSE may impact follow-up. These data support cognitive screening of substance abuse research subjects.

Identifying Sociodemographic Characteristics Associated With Burden Among Caregivers of the Urban Homebound: The Importance of Racial and Relationship Differences.

Limited research has explored whether the burden associated with caring for homebound patients varies across racial groups or by relationship status. We examined these variations for this vulnerable population. Patients self-identified informal caregivers and caregiver burden/depression were assessed using the Zarit Caregiver Burden Scale and the Center for Epidemiologic Studies-Depression scale (CES-D). Forty-nine informal caregivers completed the interview. Mean age was 58 (SD = 14), 78% were female, 37% Black, 35% Hispanic, and 46% had completed high school. Over 60% of caregivers had moderate or severe caregiver burden and 30% had significant depression. White caregivers had greater burden than Black and Hispanic caregivers (p = .02). Mean caregiver burden was higher among spouse/partner caregivers, versus those who identified as children or other family or friends (p = .004). Additional research is needed to better understand the experience of racial and ethnic minorities and spouses in providing informal care to homebound adults.

Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program-Preliminary Data.

Models addressing urgent clinical needs for older adults with multiple advanced chronic conditions are lacking. This observational study describes a Community Paramedicine (CP) model for treatment of acute medical conditions within an Advanced Illness Management (AIM) program, and compares its effect on emergency department (ED) use and subsequent hospitalization with that of traditional emergency medical services (EMS). Community paramedics were trained to evaluate and, with telemedicine-enhanced physician guidance, treat acute illnesses in individuals' homes. They were also able to transport to the ED if needed. The CP model was implemented between January 1, 2014, and April 30, 2015 in a suburban-urban AIM program. Participants included 1,602 individuals enrolled in the AIM program with high rates of dementia, decubitus ulcers, diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease. Participants had a median age of 83 and an average of five activity of daily living dependencies (range 0-6). During the study period, there were 664 CP responses and 1,091 traditional EMS transports to the ED among 773 individuals. Only 22% of CP responses required transport; 78% were evaluated and treated in the home. Individuals that community paramedics transported to the ED had higher rates of hospitalization (82.2%) than those using traditional EMS (68.9%) (P < .001). Post-CP surveys showed that all respondents felt the program was of high quality. Results support the potential benefits of CP and invite further evaluation of this innovative care model.

Symptom burden in chronically ill homebound individuals.

OBJECTIVES: To document the degree of symptom burden in an urban homebound population. DESIGN: Cross-sectional survey. SETTING: The Mount Sinai Visiting Doctors (MSVD) program. PARTICIPANTS: All individuals newly enrolled in the MSVD. MEASUREMENTS: Edmonton Symptom Assessment Scale (ESAS), which consists of 10 visual analogue scales scored from 0 to 10; symptoms include pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, shortness of breath, and other. RESULTS: ESAS scores were completed for 318 participants. Most participants were aged 80 and older (68%) and female (75%); 36% were white, 22% black, and 32% Hispanic. Forty-three percent had Medicaid, and 32% lived alone. Ninety-one percent required assistance with one or more activities of daily living, 45% had a Karnofsky Performance Scale score between 0 and 40 (unable to care for self), and 43% reported severe burden on one or more symptoms. The most commonly reported symptoms were loss of appetite, lack of well-being, tiredness, and pain; the symptoms with the highest scores were depression, pain, appetite, and shortness of breath. Participants were more likely to have severe symptom burden if they self-reported their ESAS, had chronic obstructive pulmonary disease or diabetes mellitus with end organ damage, or had a Charlson Comorbidity Index greater than 3 and less likely to have severe burden if they had dementia. CONCLUSION: In chronically ill homebound adults, symptom burden is a serious problem that needs to be addressed alongside primary and specialty care needs.

Residents contributing to inpatient quality: blending learning and improvement.

BACKGROUND: Quality improvement (QI) initiatives reduce medical errors and are an important aspect of resident physician training. Many institutions have limited funding and few QI experts, making it essential to develop effective programs that require only modest resources. We describe a resident-led, hospitalist-facilitated limited root cause analysis (RCA) QI program developed to meet training needs and institutional constraints. METHODS: We initiated a monthly quality improvement conference (QIC) at the Mount Sinai Hospital in New York City, New York. Before each conference, a third-year resident investigated a patient care issue and completed a limited RCA. At the QIC, the findings were presented to the Internal Medicine residents, followed by a chief resident and hospitalist-facilitated group discussion. All proposed interventions were recorded, and selected interventions were later implemented. The success of these interventions in achieving permanent system-wide change or resident behavior change was tracked. Residents' views on the conferences were solicited via an anonymous questionnaire. RESULTS: Twenty conferences were held over the first 22 months of the program. Twenty-five (54%) of the 46 suggested interventions were initiated. Eighteen (72%) attempted interventions resulted in system-wide change or resident behavior change. Fifty-three residents evaluated the quality of the conferences. The majority believed the conferences were high quality (98%) and led to patient care improvements (96%). CONCLUSIONS: Resident-led modified RCAs are an effective method of integrating QI efforts into resident training. As front line providers, residents are uniquely positioned to identify and implement system changes that benefit patients. Conferences were implemented without overburdening facilitators or participants.

To the hospital and back home again: a nurse practitioner-based transitional care program for hospitalized homebound people.

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.

Understanding and Improving the Burden and Unmet Needs of Informal Caregivers of Homebound Patients Enrolled in a Home-Based Primary Care Program.

The growing homebound population is heavily reliant on informal caregivers, who are increasingly burdened by their roles. This study describes informal caregivers of the homebound who remain caregivers at a 9-month follow-up and examines the impact of a home-based primary care (HBPC) program on caregiver burden and unmet needs using a prospective design with a pre-post intervention assessment. Informal caregivers of the urban homebound are similar to caregivers of other populations and have a broad range of unmet needs. The intervention described is the regular provision of multidisciplinary HBPC. Hundred fourteen caregivers of newly admitted patients complete a baseline interview. For the 56 caregivers who complete a 9-month follow-up interview, participation in HBPC is associated with a statistically significant decrease in overall caregiver burden. At 9 months, caregivers demonstrate an overall decrease in unmet needs, with a statistically significant decrease across two measured domains. These results suggest that the regular provision of multidisciplinary care in the home can mitigate the deleterious impact of informal caregiving.

The positive financial contribution of home-based primary care programs: the case of the Mount Sinai Visiting Doctors.

The coming decade will see a rise in the number of homebound seniors. These vulnerable patients have great difficulty accessing primary care. Home-based primary care (HBPC) can fill this healthcare need. Presently, such programs have been slow to develop, in part because of the perception that they are fiscal liabilities. Using the Mount Sinai Visiting Doctors (MSVD) program, the total financial effect of an HBPC program on an Academic Health Center (AHC) was assessed. A retrospective cohort analysis (n=692, 565 patient years) of Medicare-eligible individuals who were enrolled in the MSVD HBPC program was conducted. Revenues and associated costs for direct physician home care services, inpatient admissions, and outpatient clinic and emergency department visits for 1 calendar year were captured. Sensitivity analyses varying efficiency and cost variables were performed. Total direct cost for HBPC for the patient cohort was $976,350. Direct billing from home visits generated revenues that covered 24% of total direct care costs. Over a 12-month period, the cohort had 398 inpatient admissions and 1,100 non-HBPC outpatient visits, generating an overall contribution to margin of nearly $2.6 million. It is likely that this analysis underestimates the true contribution to margin, because it does not capture patient encounters at specialty clinics not in the Department of Medicine, unaffiliated medical centers, or private community-based practices. Although direct billing for HBPC programs does not generate enough revenue to meet operating costs, they can be significant revenue generators for the wider healthcare system and thus are fiscally worthy of subsidization.