Community paramedic‐delivered care transitions intervention reduces emergency department revisits among cognitively impaired patients

Abstract

Background Up to half of community‐dwelling older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We examined the effects of delivering the Care Transitions Intervention (CTI) to older adult patients with impaired cognition discharged home from the ED, hypothesizing that the CTI would decrease ED revisits in the following 30 days. Method We conducted a pre‐planned sub‐analysis of community‐dwelling older adults (age≥60 years) with impaired cognition participating in a single‐blind, randomized controlled trial testing the effectiveness of the CTI adapted for use following ED discharge. The parent study recruited ED patients from three university‐affiliated hospitals from 2016–2019. Subjects eligible for this analysis had to: 1) have a primary care provider within these health systems; 2) be discharged to a community residence; 3) not receive care management or hospice services; and 4) be cognitively impaired in the ED, as determined by a score>10 on the Blessed Orientation Memory Concentration Test. Intervention group subjects received a home visit from a trained paramedic coach within 72 hours of discharge, and up to three follow‐up phone calls during the following month. Our primary outcome was occurrence of any ED revisit within 30 days of discharge. Secondary outcomes included any ED revisit within 14 days and outpatient clinic follow‐up. We evaluated intervention effects using multivariate logistic regression. Result Of our sub‐sample (N=81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Bivariate comparison of primary and secondary outcomes found no significant differences. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (OR 0.25, 95%CI 0.07‐0.90) but not 14 days (OR 1.01, 95%CI 0.26‐3.93). Multivariate analysis of outpatient follow‐up found no significant effects. Conclusion Community‐dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.

Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review

“…34e40 The participation rate of individuals with cognitive impairment ranged from 3% to 100%, 34e40 with 2 studies targeting cognitively impaired ED patients. 35,40 The mean age of study participants ranged from 78 to 87 years, and the majority of participants were female. 34e40 No study reported the racial or ethnic backgrounds of study participants.…”

“…Of the 7 studies, 1 was a conference abstract (prospective cohort study), 39 2 were prospective cohort studies, 34,38 1 was a retrospective cohort study, 35 2 were randomized control studies, 36,40 and 1 was a quasi-randomized clinical trial. 37…”

“…34,35,37e39 Other intervention elements within multiple studies included enhanced discharge planning (eg, follow-up visits) and referrals to primary care or specialist services. 34e38, 40 The remaining study had trained community paramedics make home visits. 40 Three studies delivered interventions primarily in the ED/hospital, 35,38,39 one primarily in the home setting, 40 and the remaining 3 used a mix of home and community follow-ups.…”

“…34e38, 40 The remaining study had trained community paramedics make home visits. 40 Three studies delivered interventions primarily in the ED/hospital, 35,38,39 one primarily in the home setting, 40 and the remaining 3 used a mix of home and community follow-ups. 34,36,37 Multiple personnel were involved in intervention delivery, including geriatric trained physicians, 34,35,37,38 case management staff (eg, social workers), 34e36 nurses, 34,35,37 and occupational therapists.…”

“…34,36,39 One study included an in-person visit and up to 3 phone calls in the 30 days following discharge. 40…”