ACEP ID:

Social Emergency Medicine

Spotlight on Action - Innovative Solutions to Structural Problems

Anumeha Singh, MD, FACEP
Department Of Emergency Medicine and Traumatology
University of Connecticut, Hartford, CT

“BuddyTaping - Combining Emergency Care and Primary Care for Rural Healthcare Fix”

Significant disparities in health care exist between rural and urban areas. This is reflected by the fact that mortality rates increase with the increasing level of rurality. Despite the declining mortality trends, mortality risks for both males and females of all races have been higher in non-metropolitan than metropolitan areas. An important contributor to this has been improving healthcare in metropolitan areas leading to larger mortality reductions during the past four decades than non-metropolitan areas.1

Other factors contributing to the higher rural area mortality is the fact that rural Americans are more likely to suffer from alcoholism, mental illness, drug overdose, and suicide. Also, the rural population is older, more socially and geographically isolated, and engage more in high-risk behaviors such as smoking, opioid abuse, and lower use of seat belts.2, 3

Add to this the fact that since 2010, the rate of rural hospital closures has increased significantly. 4 The blow is even more pronounced since patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas.5

Thus, healthcare availability is paradoxically decreasing in medically underserved areas with a population who are socioeconomically at higher risk to suffer from more acute and chronic illnesses. Under such disheartening circumstances, Carolinas Healthcare System, Ansonia rose to meet this challenge with outside-the-box thinking. Like many critical access rural hospitals, the 52 bed facility in Ansonia was running in deficit. They decided to take a fresh approach to the local healthcare delivery system and came up with an entirely new model.

The County has 27,000 residents and an overall health ranking at 89th of the state’s 100 counties. 19% of the population is uninsured and only 19% have primary care. They decided to address their two greatest concerns together- the need for primary and preventive care and availability of emergency care.

Carolina Healthcare System opened up a 43,000 square feet “Medical home” with no walls dividing the space. Both primary care and emergency department providers share this “Medical Home.” The idea is brilliantly simple. An Emergency Nurse and a Physician Assistant triage the patient and then the appropriate care is provided. Patients without a primary care provider are linked to one.

The Hospital has 15 beds and averages 2-3 pts admitted overnight. They transfer most acute care case to larger hospitals. The hospital has a clinic room for rotating specialists, a pharmacy, a payment assistance program, and a mobile unit for community access for diagnostics, screening, and education. Additionally, the hospital has a behavioral health specialist and utilizes telepsychiatry when needed. They also have a van service which offers transport for people who would otherwise miss their healthcare appointments. During their first year, they transitioned about 2,600 patients to primary care.

The idea is innovative and does seem to have the potential to answer and solve some of the rural healthcare issues. There was a recent article in Annals of Emergency Medicine proposing a similar model to help solve the rural healthcare crisis, in which the authors propose a dynamic and fluid Emergency Medicine - Primary Care centered approach.6 They propose that EDs serve as a hub for emergency care, primary and preventive care, and social services to improve rural population health. This is an example of how reimagining emergency care can lead to improved, long-lasting outcomes for underserved communities.

Margaret Greenwood-Ericksen, the first author of the article proposing EM-PC partnership shares some of her personal thoughts, expected barriers to the model and possible solutions.

She sees the current fee-for-service mentality of health care presenting a barrier to implementation of novel, innovative health care delivery transformation that focuses on prevention/population health. One of her proposed solutions is to pair innovations with payment reforms like global budgets. An obvious issue with using EDs is that traditionally hospitals bill at a higher rate for the visits and also bill a facility fee. Hence an ED visit is "more expensive," than a primary care visit. Dr. Greenwood-Ericksen’s global budget financial model flips the traditional fee-for-service incentive structure on its head. She predicts it will create a powerful incentive to transform care for prevention while reducing admissions and invest in community services.

References

  1. Singh GK, Siahpush M. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009. J Urban Health. 2014;91:272-292.
  2. Eberhardt MS, Pamuk ER. The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health. 2004;94:1682-1686.
  3. Hartley D. Rural health disparities, population health, and rural culture. Am J Public Health. 2004;94:1675-1678.
  4. Kaufman BG, Thomas SR, Randolph RK, et al. The Rising Rate of Rural Hospital Closures. J Rural Health. 2016;32:35-43.
  5. About Rural Healthcare: National Rural Healthcare Association. https://www.ruralhealthweb.org/about-nrha/about-rural-health-care
  6. Greenwood-Ericksen MB, Tipirneni R, Abir M. An Emergency Medicine-Primary Care Partnership to Improve Rural Population Health: Expanding the Role of Emergency Medicine. Ann Emerg Med. 2017;70:640-647.
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