Effect of a Home Health and Safety Intervention on Emergency Department Use in the Frail Elderly: A Prospective Observational Study.

INTRODUCTION: Geriatric patients are often frail and may lose independence through a variety of mechanisms including cognitive decline, reduced mobility, and falls. Our goal was to measure the effect of a multidisciplinary home health program that assessed frailty and safety and then coordinated ongoing delivery of community resources on short-term, all-cause emergency department (ED) utilization across three study arms that attempted to stratify frailty by fall risk. METHODS: Subjects became eligible for this prospective observational study via one of three pathways: 1) by visiting the ED after a fall (2,757 patients); 2) by self-identifying as at risk for falling (2,787); or 3) by calling 9-1-1 for a "lift assist" after falling and being unable to get up (121). The intervention consisted of sequential home visits by a research paramedic who used standardized assessments of frailty and risk of falling (including providing home safety guidance), and a home health nurse who aligned resources to address the conditions found. Outcomes of interest were all-cause ED utilization at 30, 60, and 90 days post-intervention compared with subjects who enrolled via the same study pathway but declined the study intervention (controls). RESULTS: Subjects in the fall-related ED visit arm were significantly less likely to have one or more subsequent ED encounters post-intervention than controls at 30 days (18.2% vs 29.2%, P<0.001); 60 days (27.5% vs 39.8%, P<0.001); and 90 days (34.6% vs 46.2%, P<0.001). In contrast, participants in the self-referral arm had no difference in ED encounters post-intervention compared to controls at 30, 60, or 90 days (P=0.30, 0.84, and 0.23, respectively). The size of the 9-1-1 call arm limited statistical power for analysis. CONCLUSION: A history of a fall requiring ED evaluation appeared to be a useful marker of frailty. Subjects recruited through this pathway experienced less all-cause ED utilization over subsequent months after a coordinated community intervention than without it. The participants who only self-identified as at risk for falling had lower rates of subsequent ED utilization than those recruited in the ED after a fall and did not significantly benefit from the intervention.

Creating a process for incorporating epidemiological modelling into outbreak management decisions.

Modern computational models of infectious diseases greatly enhance our ability to understand new infectious threats and assess the effects of different interventions. The recently-released CDC Framework for Preventing Infectious Diseases calls for increased use of predictive modelling of epidemic emergence for public health preparedness. Currently, the utility of these technologies in preparedness and response to outbreaks is limited by gaps between modelling output and information requirements for incident management. The authors propose an operational structure that will facilitate integration of modelling capabilities into action planning for outbreak management, using the Incident Command System (ICS) and Synchronization Matrix framework. It is designed to be adaptable and scalable for use by state and local planners under the National Response Framework (NRF) and Emergency Support Function #8 (ESF-8). Specific epidemiological modelling requirements are described, and integrated with the core processes for public health emergency decision support. These methods can be used in checklist format to align prospective or real-time modelling output with anticipated decision points, and guide strategic situational assessments at the community level. It is anticipated that formalising these processes will facilitate translation of the CDC's policy guidance from theory to practice during public health emergencies involving infectious outbreaks.