Outcomes of home‐based primary care for homebound older adults: A randomized clinical trial

Section: Demo Year Sites With Savings Beneficiaries % Savings Savings...mentioning

confidence: 97%

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confidence: 95%

The challenge of proving the value of medical care in the home

Boling

Kinosian

2022

“…[7][8][9][10] Home-based primary care is one model of healthcare delivery that supports aging in place by bringing care directly into the patient's home. [11][12][13] However, this approach is limited in its ability to accommodate sameday or urgent evaluations routinely, due to ambitious schedules and the additional time required for nonreimbursable patient care, most notably, drive time for providers scattered across a given service area. [14][15][16][17] Telemedicine has been proposed as a work-around to this issue; however, over one-fourth of patients in home-based care are unable to interact over video for telehealth.…”

Section: Introductionmentioning

confidence: 99%

“…In addition to increased cost and fragmentation of care, exposure to these settings increases the risk of acute care‐associated adverse events in older adults 7–10 . Home‐based primary care is one model of healthcare delivery that supports aging in place by bringing care directly into the patient's home 11–13 . However, this approach is limited in its ability to accommodate same‐day or urgent evaluations routinely, due to ambitious schedules and the additional time required for non‐reimbursable patient care, most notably, drive time for providers scattered across a given service area 14–17 .…”

Section: Introductionmentioning

confidence: 99%

Addition of community paramedics to a physician home‐visit program: A prospective cohort study

Ulintz,

Podolsky,

Lapin

et al. 2023

BackgroundHome‐based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in‐home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model.MethodsThis prospective cohort study enrolled older adults in home‐based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30‐day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR).ResultsWe screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76–86 years, with 3–5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06–1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48–1.18) or 30‐day readmissions (IRR 1.32, 95% CI 0.49–3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001).ConclusionOlder adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations.

“…Most evidence about the impact of scope-of-practice regulations is focused on NP care in ambulatory or inpatient settings and shows that full scope-of-practice policies increase access to NP care, particularly for lowincome adults with a greater shortage of primary care clinicians, and rural residents [18][19][20][21][22] These findings may not be generalizable to care provided in a patient's home environment. Access to HBPC is particularly important for homebound older adults because of its associations with fewer hospitalizations/emergency room visits, 4,23 higher rates of advance care planning, 24 and coordinated care required to enable homebound adults to remain in their own homes and out of nursing home settings. 25 With the NP workforce expected to nearly double in upcoming years, 2,26 and states progressively expanding NP scope-of-practice regulations to allow NPs to care for patients without physician oversight, 27 the growing numbers of NPs may be deployed to meet this growing demand for HBPC.…”

Section: Introductionmentioning

confidence: 99%

The role of restrictive scope‐of‐practice regulations on the delivery of nurse practitioner‐delivered home‐based primary care

Osakwe

Liu

Ankuda

et al. 2023

Self Cite

Background Nurse practitioners (NPs) are the largest group of providers delivering home‐based primary care (HBPC) in the U.S. We examined the association of scope‐of‐practice regulations and NP‐HBPC rates. Methods Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state‐level analysis to examine the impact of scope‐of‐practice regulations on the utilization of NP‐HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341–99,345, 99,347–99,350) and domiciliary settings (99324–99,328, 99,334–99,337). We used linear regression to compare NP‐HBPC utilization rates between states of either restricted or reduced scope‐of‐practice laws to states with full scope‐of‐practice, adjusting for a number of NP‐HBPC providers, state ranking of total assisted living, the proportion of fee‐for‐service (FFS) Medicare beneficiaries and neighborhood‐level socio‐economic status and race and ethnicity. Results Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope‐of‐practice, states with restricted or reduced scope‐of‐practice had higher adjusted rates of NP‐HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP‐HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full‐ scope‐of‐practice laws, respectively. The rate of NP‐HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13–1.72; p = 0.023) and reduced scope‐of‐practice laws (Beta coefficient = 0.91; 95%CI 0.03–1.79; p = 0.043) compared to states with full scope‐of‐practice laws. Conclusion Restricted state NP scope‐of‐practice regulations were associated with higher rates of FFS Medicare NP‐HBPC care delivery compared with full or reduced scope‐of‐practice. Understanding underlying mechanisms of how scope‐of‐practice affects NP‐HBPC delivery could help to develop scope‐of‐practice regulations that improve access to HBPC for the underserved homebound population.