Going to the Emergency Room Without Leaving the Living Room
Geriatricians have issued stark warnings about how hospitalization can cause elderly patients to decline more rapidly, even if their medical issue is dealt with. Vulnerabilities to infection, issues of mobility, bad drug interactions, and delirium are all problems that can arise for older patients admitted to hospital, leading to new programs of care that do not involve hospital care. Community paramedic practices are becoming more common, offering scheduled home visits by paramedics or mobile healthcare providers to help alleviate these issues and provide elderly patients with the opportunity to remain in comfort. Rather than sending older healthcare patients unnecessarily to the hospital even if they do not require injury treatment, home services can assess healthcare needs accurately in the patients’ home. If insurance programs such as Medicare and Medicaid cover at-home treatments in future, this strategy is likely to make elderly healthcare more sophisticated.
Differing state regulations mean that these efforts take many forms. In Fort Worth, Medstar Mobile makes mostly scheduled visits, not emergency calls; its paramedics (called mobile health care providers) more often help patients learn to manage their chronic illnesses. When a diabetic has low blood sugar, Mr. Zavadsky said, “we can administer IV dextrose, or make them a good dinner.”

What the programs share are the additional training, a team approach and an emphasis on preventing unnecessary transport. “The concept of using your E.M.S. people to keep people out of the hospital is common to all of them,” said Dan Swayze, the vice president of the Center for Emergency Medicine of Western Pennsylvania in Pittsburgh.

The concept may spread even faster if insurers, particularly Medicare and Medicaid, would cover at-home treatment by paramedics. Right now, emergency services are reimbursed only for ferrying people to hospitals.

“If we only pay to transport people, guess what we’re going to do,” Mr. Zavadsky said.

That could change, though. Medstar Mobile and other programs are negotiating with insurance companies for reimbursement for at-home services, instead of relying on foundation grants, referral payments and hospital budgets. Supporters are also pressing the Centers for Medicare and Medicaid Services to change its policies.

Northwell Health’s community paramedics program published its results this summer in The Journal of the American Geriatrics Society, looking at outcomes for 1,602 ailing, homebound patients (median age: 83) over 16 months. When the community paramedics responded — most commonly for shortness of breath, neurological and psychiatric complaints, cardiac and blood pressure problems, or weakness — they were able to evaluate and treat 78 percent of patients at home.