Abstract
Objective
As the number of older adults living in the United States grows, the gap between the capacity of home-based primary care (HBPC) services and the community demand will continue to widen. Older adults, living longer with mobility difficulties and multiple chronic medical conditions, often prefer to age in place, and new models of care are needed to meet this need. This article provides a framework for an innovative emergency medical technician (EMT)-facilitated telehealth program, the mobile telemedicine technician (MTT) program, which aims to increase access to medical care and efficiency within an HBPC program.
Design
A descriptive framework outlining the deployment of an innovative telehealth model.
Setting
An HBPC program serving homebound seniors in downstate New York.
Participants
Homebound individuals enrolled in an HBPC program with advanced age (over half >90 years), 67% with 5–6 activities of daily living (ADL) dependencies, and high rates of dementia, congestive heart failure, chronic obstructive pulmonary disease (COPD), and diabetes requiring evaluation and treatment of acute conditions.
Interventions
HBPC program enrollees requiring evaluation and treatment of acute conditions received a home visit from a telehealth-enabled EMT who has received additional training to provide in-home care. Following an evaluation, the EMT facilitated a telehealth visit via a two-way video conference between the patient and the primary care physician.
Main outcome measures
Description of a novel telehealth care model, preliminary results from the first 100 MTT visits including the reason for visit, patient/caregiver, physician, and telehealth-enabled EMT satisfaction survey results.
Results
The primary care provider was able to evaluate twice as many patients in a given time period using the new model as in the regular home visit care model. The most common visit reasons were related to skin conditions (22%), neurological conditions (19%), cardiovascular conditions (16%), and respiratory conditions (15%). Satisfaction rates were high from patients/caregivers (45% response rate, 60% strongly agreed and 29% agreed that they were satisfied with the care delivery experience), physician (six surveys over time from one physician, 100% strongly agreed on the effectiveness of care delivery model), and telehealth-enabled EMTs (eight surveys from four EMTs, 100% strongly agreed that they were satisfied with the care delivery experience).
Conclusions
In this descriptive article, we outline a new model of care using telehealth-enabled EMTs making home visits to connect with a patient’s primary care physician who is centrally located. This model shows promise for expanding primary care services within the home.
Introduction
While approximately 2 million adults aged 65 and older are currently considered homebound,1the number of older adults living in the United States is expected to grow to more than 20% of the population by 2060,2,3 likely increasing the number of homebound individuals substantially. Homebound adults aged 65 and older often have multiple chronic conditions and greater functional limitations than nonhomebound older adults.4 For these individuals, leaving the home for medical care is often difficult, and, when a medical issue arises, they may initially go without or delay care. This lack of primary care services can lead to an overreliance on emergency medical and hospital services. Evidence supports that older adults and homebound individuals use emergency medical services (EMS) at a disproportionately higher rate and are more likely to be hospitalized than younger adults and nonhomebound individuals, respectively.5
Home-based primary care (HBPC) is a medical model that transitions patient-centered care from outpatient clinics to the patient’s home. HBPC has been shown to improve the quality of life and satisfaction with care for older adult patients and reduces the burden on their caregivers.6Additionally, HBPC improves access to medical care while reducing hospitalizations and total cost of care.7 HBPC uses an interdisciplinary team (IDT) that includes nurse, social worker, and physician or nurse practitioner to deliver care to patients with multiple chronic conditions such as dementia, congestive heart failure and/or diabetes, and functional status decline. HBPC allows older adults to age in place, which data show is preferred by the majority of older adults, and is beneficial for mental and physical health. Unfortunately, the need for HBPC services outstrips capacity. Analysis of 2013 Medicare fee-for-service program data showed that the majority of Americans lack access to HBPC by living more than 30 miles from a high-volume (1,000 or more visits) HBPC program.8 Further compounding this provider shortage is the high cost of operating an HBPC practice which is physician-intensive and relies on high-touch models of care. In order to grow programs to meet the needs of communities across the country, HBPC practices will need to explore innovative care models, and telehealth may be one such option.
In this article, we describe and present preliminary data for an innovative emergency medical technician (EMT)-facilitated telehealth program, the mobile telemedicine technician (MTT) program, that was implemented in a downstate New York HBPC practice. The model builds on the practice’s prior experience in telehealth deployment and aims to increase access to medical care and efficiency within the program by allowing twice the number of patient evaluations as would be possible using a traditional in-home visit structure. In addition to visit statistics, preliminary data regarding the satisfaction of patients/caregivers, physicians, and telehealth-enabled EMTs are presented. This article aims to provide a framework for an EMT physician extender model and to inform the growing fields of both telehealth as well as HBPC.