ED Rx: care in the community

Emergency departments (EDs) across Canada are under strain, leading to overcrowding and long patient wait times, putting health and lives at risk and contributing to healthcare provider and staff overwork and burnout.While solving issues related to flow through the ED and access to the proper followup, such as inpatient or home care, are critical, addressing the factors that influence the need for ED services in the first place is vital to solving the emergency crisis.Dr. Shazma Mithani, an emergency physician at the Royal Alexandra and Stollery Children’s Hospitals in Edmonton, says a key step is improving access to high-quality primary care and preventive medicine.Primary care foundational“If somebody’s high blood pressure is managed, they’re much less likely to have a stroke or a heart attack. If somebody’s COPD is well managed, they’re not going to come to the emergency department,” Dr. Mithani said. “Primary care is the foundation of the healthcare system because it supports all of it and when it’s working well, it keeps people out of the ER and takes the pressure off of us there.”Dr. Mithani says this is even more true when a patient has a “medical home” that provides team-based primary care. Indeed, a study in the January 2022 Annals of Family Medicine found that, while ED visits have been increasing for all patients in Ontario, patients who were part of a team had a lower increase in ED visits over time. In a 2017 review of research by the College of Family Physicians of Canada on practices aligned with patient’s medical home principles, 84% of studies reviewed show reduced ER visits and hospitalizations in patients with chronic disease.But in a survey of more than 9,000 Canadians, only 15% of respondents said they had access to health professionals in their primary care clinic beyond a doctor, nurse or nurse practitioner. Team-based care models are slowly expanding in Canada, with Ontario and Quebec leading the way. In Ontario, about 25% of people have access to a primary care team, while in Quebec, 65% of people access a family medicine group.Here are some solutions:Familiar Faces programAbout 185,000 people visit the ED across Niagara Health in the Niagara region of Ontario each year. In 2021, data showed that almost 4,000 people visited more than five times a year, representing 25,000 visits annually.“The ED is where people come when they have nowhere else to turn,” said Laura Farrelly, director of emergency and urgent care at Niagara Health. “When we looked at the data, we saw that the reason these patients were coming weren’t really for medical care. It was more for some type of support that they weren’t able to access in the community.”So they created the Familiar Faces program, which includes a social worker in the ED and collaborates with primary care partners, community care clinics and chronic disease management programs to build care plans to link patients with needed resources and support.“It helps the people navigate care in the community and hopefully they won’t feel the need to come to the ED,” Farrelly said.The health system also created the similar Wellness Recovery Integrated Complex Care (WRICC) program for adults with complex mental health needs who have repeated ED visits and two inpatient stays in a year.“When we started, our focus was length of stay in emerg and reducing ED visits, but I think the bigger benefit we saw was that we provide more comprehensive care. It helps build their resilience and their ability to manage their own needs,” she said.While outcome data is preliminary, Farrelly says the health system is seeing significant numbers of people dropping off the Familiar Faces list (fewer repeat visits). In 2023, there was a 32.3% reduction in ED visits in patients who had participated in the WRICC program.PROTECT Connected Health programThrough Hamilton, Ont.’s Hamilton Health Sciences’ “Perioperative Risk and imprOving health outcomes Through innovation Excellence and application of digital health remote monitoring and imaging Technologies” (PROTECT) Connected Health program, patients recovering from cancer surgery and other surgeries are sent home with technology that allows physicians and nursing staff to monitor them virtually.Physicians and nurses can identify patients who need medical care and help them avoid a trip back to the hospital. Patients are given a tablet and remote monitoring equipment to assess vital signs. Nurses educate patients on how to use the technology prior to discharge.“Patients leave the hospital, but in every other respect, they are still under the care of a team of nurses and physicians with 24/7 coverage, typically for 14 days. There is daily rounding and patients send their vital signs three times a day and respond to surveys on how they are feeling,” said Ted Scott, president of innovation and partnerships, Hamilton Health Sciences.Scott says patients can go home sooner after surgery and the hospital has seen a significant reduction in readmissions. “If we do have to send patients to the ED, we can call ahead and schedule it,” he said. “But typically, we redirect them to acute care clinics. We are providing interventions that reduce unscheduled care, which results in less reliance on the ED.”

ED Rx: care in the community

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