Emergency Medicine’s Role in Home-Based Care

By David Whitehead, MD; Emily Hayden, MD; Benjamin White, MD; Brian Yun, MD; and Stephen Dorner, MD, on behalf of the SAEM ED Administration and Operations Committee Background

As hospitals nationally struggle with capacity challenges, emergency department (ED) crowding has worsened again, increasing demand for alternative ways to care for patients. ED observation units (EDOUs), once thought of as an “alternative” care pathway, have grown significantly in number and provide care for patients needing prolonged monitoring and/or additional testing. Now mainstream, the growth and success of EDOUs have demonstrated that they can preserve ED resources and provide financial benefit to hospitals. Amidst the COVID-19 pandemic, in recognition of constraints on in-hospital space, the Centers for Medicare and Medicaid Services (CMS) launched the Hospital Without Walls (HWW) waiver authorizing the use of telehealth and non-traditional spaces such as patients’ homes to provide what has historically been hospital-based care. Enterprising EDs have seized on the opportunity created by CMS to expand their clinical skill set into alternative sites of care via mobile urgent care and virtual observation units.

Model

Extending the reach of emergency medicine (EM) beyond the walls of the hospital and into patients’ homes is possible through a mobile integrated health (MIH) care platform: pairing a specially trained paramedic with portable diagnostics and therapeutics with real-time medical direction from

a prescribing clinician. The HWW waiver made the MIH model of care more financially viable through the reimbursement of telehealth services, which the paramedic can facilitate via chat- and video-based telehealth while in a patient’s home. Medical systems can dispatch mobile urgent care units to evaluate patients with urgent medical needs who a) may not be able to access telehealth, b) experience issues outside of regular clinic hours, or c) require roundtrip EMS transport to receive in-person medical care.

The same MIH model of care can be used to provide observation level care for patients enrolled in virtual ED observation units. Also possible through the HWW waiver, home-based virtual observation units (VOUs) are particularly well-suited to care for patients with conditions typically treated in hospital-based observation units, including cellulitis, diverticulitis, COPD exacerbations, heart failure, and COVID-19 pneumonia, among others. Patients are enrolled after being evaluated in an ED and meeting CMS criteria for observation level of care. Thereafter, VOU patients have access to similar services available in hospital-based observation units from the convenience of their own home: vital sign monitoring, nursing evaluations via phone or video calls, inhome paramedic assessments inclusive of medication administration and lab draws, and virtual care from an EM clinician.

Benefits

Although new in structure from a regulatory and financial perspective, the MIH model of care relies on the triedand-true pairing of emergency medicine and paramedicine. Early experience with both mobile urgent care and virtual ED observation units suggests improved patient experience, a reduction in ED boarding, improved equity in access to home-based and virtual care, and improved provider satisfaction. Moreover, patients are likely to experience less testing and have increased mobility in their home environment, as has been demonstrated through inpatient hospital at home programs.

Future

Extending the skillset of trained EM physicians into the home-based space through MIH holds significant promise in providing safe, effective, patient-centered, and convenient care while addressing mounting ED and hospital capacity challenges. Despite the early success of the models, many health systems have not pursued their development because the regulatory and financial framework authorizing them are due to expire with end of the public health emergency, creating an uncertain future. We anticipate that with increased reimbursement clarity and evidence of the positive impact virtual ED observation units and mobile urgent care have on patient care, that these models will have increasing adoption nationally in the coming years.

ABOUT THE AUTHORS

Dr. Whitehead is an emergency medicine resident at the Harvard Affiliated Emergency Medicine Residency at Mass General Brigham.

Dr. Hayden is the director of telehealth and associate director of the virtual observation unit, department of emergency medicine, Massachusetts General Hospital, and was the chair of the 2020 SAEM Consensus Conference: Telehealth in EM.

Dr. White is the director of the Center for EM Innovation and ED and Virtual Observation Unit in the department of emergency medicine at Massachusetts General Hospital.

Dr. Yun is the vice chair of clinical affairs in the department of emergency medicine at Boston Medical Center. Prior to this, he was the director of clinical operations for the emergency department at Massachusetts General Hospital.

Dr. Dorner is a practicing emergency physician at Massachusetts General Hospital, assistant medical director for home-based care at Mass General Brigham, and assistant medical director in the Massachusetts General Hospital Center for Telehealth.