Health Policy Journal Club, Health Policy, Advocacy, Health Care Administration, EMS, Palliative Care

Health Policy Journal Club: The Comforts of Home

Collaboration between hospice staff and EMS can reduce patient transport to the ED 

Hospice care provides symptom-focused treatment for patients experiencing life-limiting illness, along with support for caregivers. While hospice often occurs in home settings, acute exacerbations of symptoms may lead patients and families to contact emergency medical services (EMS) for transport to the emergency department (ED). Hospice care focuses on comfort and quality of life, whereas the EMS system is designed to prevent death and disability via resuscitation and transport to an ED. A previous survey found that over 80% of EMS providers had cared for hospice patients and desired additional training in end-of-life care.

Mobile Integrated Hospice Healthcare (MIHH) is an innovate model for integration of hospice care services into EMS. A recent study examined the impact of an MIHH program in California to educate paramedics on supporting patients and families and coordinating care with hospice agencies. Paramedics with at least 4 years of prior experience completed a 30-hour training course in palliative care and grief counseling, including clinical exposure on home visits with hospice nurses. California also approved an expanded EMS scope of practice to administer atropine drops, promethazine, morphine, and lorazepam for end-of-life symptom management. The protocol for MIHH teams engaged hospice nurses to implement patient-centered care plans.

Prior to implementation, approximately 80% of hospice patients who contacted 911 were transported to the ED. After 3 years of MIHH, the number of hospice patients taken to the ED significantly declined, with only 19.6% requiring transport. Many of these cases involved falls and injuries that required emergency care but still aligned with the goals of hospice. Surprisingly, paramedic teams very rarely used the expanded scope of practice to administer medications. For most EMS calls, the hospice education, grief counseling, and coordination with hospice nurses allowed patients to remain at home and avoid unnecessary transport. Importantly, many hospice agreements do not permit patients to seek hospital admission without first consulting their hospice agency, resulting in loss of benefits. The MIHH program helps ensure that patients can maintain hospice care at home.

The MIHH program showed that collaboration between hospice staff and EMS can reduce patient transport to the ED. Supplying EMS providers with communication training and hospice education can improve care for patients and their families. 

ABSTRACT: Breyre A, Taigman M, Salvucci A, Sporer K. Effect of a Mobile Integrated Hospice Healthcare Program on Emergency Medical Services Transport to the Emergency DepartmentPrehosp Emerg Care. 2021;March:1-8.

STUDY OBJECTIVE: To evaluate the effect of a Mobile Integrated Hospice Healthcare (MIHH) program including hospice education and expansion of paramedic scope of practice to use hospice medication kits. Primary outcome was the effect on hospice patient transport to the Emergency Department. Secondary outcomes included reasons for patient transport and review of MIHH kit utilization. 

METHODS: In 2015, the project was implemented in Ventura County, California in collaboration with the county emergency medical services (EMS) agency, first response/transport organizations, and hospice programs. Paramedic supervisors received 30 hours of hospice training focusing on palliative care and grief/crisis counseling. When 9-1-1 was called for a patient, EMS first responders arrived on scene, determined a patient was enrolled in hospice, and then contacted trained MIHH.

RESULTS: Six months (2/2015-7/2015) prior to project implementation the percentage of hospice patients transported to the ED averaged 80.3% (98/122). During the first (8/2015-7/2016), second (8/2016-7/2017) and third year (8/2017-7/2018) after project implementation, the percentage of hospice patients transported to the ED was 36.2% (68/188), 33.2% (63/190) and 24.8% (36/145) respectively. A total of 523 hospice patients were cared for by MIHH during this three-year interval. Of those hospice patients transported, the most common reason for transport was fall/trauma. The MIHH hospice kit was only used once in the field. Odds ratio for hospice transportation to the ED before and after project implementation was 0.125 (95% Confidence Interval: 0.077 to 0.201; p < 0.0001). This represents an absolute reduction risk of 46.6% (95% Confidence Interval: 38.53% to 54.72%). 

CONCLUSION: MIHH decreased the transportation of hospice patients to the ED. MIHH provided hospice education, provided family grief support and developed treatment plans with hospice nurses. An expanded scope of practice, including a paramedic hospice kit, was not contributory to this decrease.

PMID: 33689535 

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.