A multifaceted primary care practice-based intervention to reduce ED visits and hospitalization for complex medical patients: A mixed methods study

• Published in: PloS one Vol. 14; no. 1; p. e0209241
• Main Authors: O'Brien, Tara, Ivers, Noah, Bhattacharyya, Onil, Calzavara, Andrew, Pus, Laura, Mukerji, Geetha, Friedman, Steven M, Abrams, Howard, Stanaitis, Ian, Hawker, Gillian A, Pariser, Pauline
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 02-01-2019; Public Library of Science (PLoS)
• Subjects: Adult; Aged; Ambulatory care; Analysis; Chronic illnesses; Communities; Community; Comorbidity; Emergency medical services; Emergency Medical Services - statistics & numerical data; Emergency Service, Hospital; Female; Health care; Health care networks; Health care policy; Hospital emergency services; Hospitalization; Hospitals; Humans; Interdisciplinary aspects; Interrupted Time Series Analysis; Intervention; Male; Medical personnel; Medical screening; Medicine; Medicine and Health Sciences; Methods; Middle Aged; Mixed methods research; Ontario; Optimization; Outcome Assessment, Health Care; Patients; People and Places; Physicians; Physicians, Primary Care; Preventive Health Services - methods; Primary care; Primary health care; Primary Health Care - methods; Primary Health Care - standards; Primary Health Care - statistics & numerical data; Private Practice; Propensity Score; Qualitative research; Quality control; Quality Improvement; Systematic review; Teams; Time series; Ontario; United Kingdom > UK; Toronto Ontario Canada; Canada
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0209241

The management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices.
An interrupted time series design and qualitative interviews were used to evaluate a multifaceted intervention, SCOPE (Seamless Care Optimizing the Patient Experience), offered to solo PCPs whose patients were frequent users of the ED. The intervention featured a navigation hub (nurse, homecare coordinator) to link PCPs with hospital and community resources, a general internist on-call to provide phone advice or urgent assessments, and access to patient results on-line. Continuous quality improvement (QI) strategies were employed to optimize each component of the intervention. The primary outcome was the relative pre-post intervention change in ED visit rate for patients of participating practices compared with that for a propensity-matched control group of physicians over the contemporaneous period. Themes were identified from semi-structured interviews on PCP's experiences and influential factors in their engagement. Twenty-nine physicians agreed to participate and were provided access to the intervention over an 18-month time period. There were a total of 1,525 intervention contacts over the 18-months (average: 50.6±60.8 per PCP). Both intervention and control groups experienced a trend towards lower rates of ED use by their patients over the study time period. The pre-post difference in trend for the intervention group compared to the controls was not significant at 1.4% per year (RR = 1.014; p = 0.59). Several themes were identified from qualitative interviews including: PCPs felt better supported in the care of their patients; they experienced a greater sense of community, and; they were better able to provide shared primary-specialty care.
This multifaceted intervention to support solo PCPs in the management of their complex patients did not result in a reduced rate of ED visits compared to controls, likely related to variable uptake among PCPs. It did however result in more comprehensive and coordinated care for their patients. Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs.