Adapting Emergency Care to Treat Patients at Home

In early 2020, as the pandemic was hitting the U.S., Cleveland Clinic leaders activated emergency plans that included restricting building access to minimize exposure of coronavirus infection for caregivers and patients. In anticipation of the patient surge, this prompted emergency providers to change patient triage to drive down utilization of the hospitals.

The team at Cleveland Clinic Community Care (4C), with its population health approach in the community, decided to leverage its Medical Care at Home program for the homebound. The collaboration now allows physicians to better address community need through its Virtualist and Urgent Dispatch programs.

Judy Welsh, MD, FACEP, Associate Chief Experience Officer, Medical Director for Community Care Medicine, explains, “The ED is not the place for primary and preventive care. So when COVID-19 hit our community, an innovative partnership filled a need while providing care for patients by meeting them where they are.”

Jan Bautista, MD, Medical Director of the Virtualist program in 4C, explains, “Initially, our team of paramedics brought tablets to patients’ homes to allow for virtual visits with physicians when patients were physically unable to go to outpatient appointments.”

The Community Paramedicine Program, launched in 2017, dispatches paramedics to the home to assess the patient, develop a treatment plan and work with physicians who are virtually present via iPad; these paramedics also visit patients transitioning home from acute hospitalization. Since then, the paramedics have steadily increased support for patients in the home by expanding their skills and working at the top of their license.

Dr. Welsh explains, “In the state of Ohio, to manage paramedics, you have to be a board-certified Emergency Physician. I have the credentials and interest and started with the team in January of 2019. Our virutalist physicians wanted more testing or bloodwork at home and our paramedics learned, along with improving documentation and assessment skills, and evolving their overall knowledge of general medicine, especially acute care.” This means the paramedics can draw bloodwork, and perform acute interventions such as IV fluids for dehydration, administer STAT medications, and conduct wound assessments in order to keep patients safe at home.

Subsequently, Cleveland Clinic Community Care launched the Virtualist program in 2019 to reduce inappropriate emergency department (ED) utilization. If patients did not require an ED visit, the Virtualists ensured that patients could be safely navigated back to their primary care teams or be treated telephonically with medical advice, prescription, or labs. In the first year of the program, the program was able to successfully thwart 1,500 ED visits.

Enter COVID-19 in 2020

Early on, amidst confusion and fear in the community of COVID-19 spread, there was concern that patients were deferring critical healthcare and screenings. After evaluating the value of the new partnership between the Virtualist and Community Care Medicine, 4C leaders expanded the urgent dispatch program across specialties to proactively evaluate patient care needs by the paramedics beyond the homebound setting to capitalize on value-based care.

Dr. Welsh continues, “At the start of the year we refined the skillset of the paramedics to develop Stat Medic paramedics who have advanced training so they can administer medication with a physician’s order and obtain bloodwork. We realized an opportunity for the stat medics to provide care for not only homebound patients but for patients with chronic diseases who experienced escalations of their symptoms. It was at that point that the Virtualist program was optimized in combination with urgent dispatch.”

The federal government has made telehealth services easier to implement and access, encouraging healthcare systems to optimize when available and appropriate. This has been particularly significant in managing patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD).

Recognizing how mobile technology was boosting outcomes, digital health teams were driving technical innovation to meet the needs of physicians by expanding the patient-engagement platform available on smartphone and web-based platforms. The tablets proved to be a conduit for communication and information management.

Dr. Bautista continued, “Virtual visits existed but there were no programs that involved bringing technology to people who didn’t have it. As it developed, we were not aware of anyone else in the country doing something quite like this.”

Cleveland Clinic Community Care Model Tested During Pandemic

Formerly known as the Medicine Institute, Cleveland Clinic Community Care brings together the primary care groups of Family Medicine, Internal Medicine, Geriatrics and General Pediatrics, By removing barriers, 4C can work as one unit to develop technologies and workflows to support the future of healthcare.

For example, responding with urgent dispatch and reserving hospital stays for the most critical patients. The unique collaboration demonstrates a significant benefit to the quality of care and clinical outcomes.

In a cohort of over 100 patients, the community paramedicine program reported:

• Decreased ED visits by 60%
• Hospital admission decreased by 49%
• Significant decrease in wait times for post-hospital and urgent visits

“What I love most about 4C is that we are trying new and interesting ways to provide the right care for the right patient at the right time,” Dr. Welsh described the softer skills tapped to move forward with constant changes. “We talk about cases frequently in order to improve. Our program manager helped to organize and keep us aligned to what matters most. We had a lot of support from our executive leadership, Nirav Vakharia, MD, Associate Chief of Value Based Operations. In particular, he raised questions to guide us to understand what’s most important to patients and to the enterprise. Everyone really had a role in this process.”

“When COVID-19 hit, our teams rose to the challenge to provide continuity of care to patients,” says Dr. Vakharia. “In a matter of days, we identified those most vulnerable, developed new partnerships both within Cleveland Clinic, as well as within the communities we serve and mobilized a new model of care. In this world where we can have groceries and goods delivered to our doorsteps within hours, our teams showed we can deliver the same level of service in healthcare and that the resultant outcomes are superior to the traditional approach.”

Michele Acheampong, MPH, Cleveland Clinic Community Care program manager, reflects with pride on the teams’ recent accomplishments, “Over the past six months, 4C has nimbly merged the building blocks of these two unique programs, the Virtualist program and the Paramedicine program, to support a large group of patients, to treat and track early, and monitor high-risk situations. With barriers removed, we are better able to serve the right care for the right patient at the right time, and serve the greater community.”