Physicians Want Improved Procedures for Referring to Home-Based Care


Referral pathways could help reduce patient admissions to hospitals, a new study suggests.

According to a recent survey, most emergency physicians (EPs) have experience ordering home-based care, but they don’t order it as often as they would if improved procedures were in place to facilitate the process.

Edward Castillo MD MPH

Edward Castillo MD MPH

Edward Castillo, MD, MPH

The findings suggest there may be untapped potential for reducing hospital admissions, a large proportion of which occur in emergency departments (EDs). Recent estimates figure that older adults presenting to the ED are admitted at almost 4 times the rate of the general population, with nearly 70% of hospital admissions for patients aged 65 years and older originating in the ED.

According to the study’s lead author, Edward Castillo, MD, MPH, of the Department of Emergency Medicine at the University of California, San Diego, home-based care can provide an important alternative to counter this trend.

“One of the biggest surprises after conducting this study was that over half of the [physician] respondents have ordered home-based care as an alternative to a hospital admission or observation. But its use is limited, mainly because there is no process in place to refer to home-based care, including processes for ensuring the proper home environment,” Castillo told MD Magazine.

Indeed, survey results showed that 73% of responding EPs ranked an “unsafe or unstable home environment” as a “strong” or “very strong” barrier that might influence their decision to discharge patients directly to home-based care instead of the hospital after an emergency department visit.

Three process-related barriers earned strong or very strong rankings from roughly two-thirds of respondents — “lack of process to transition to managing MD,” “No existing process in place to refer to home-based care,” and “unavailability of care coordinator/case manager.”

Physicians were also asked to rank perceived motivators for selecting home-based rather than hospital admission after an ED visit. 79% of respondents ranked “better setting to care for low-acuity chronic conditions or acute disease exacerbation” as either a “strong” or “very strong” motivator in this case.

Close behind, 78% of respondents said reducing unnecessary hospitalizations and observations stays was a strong or very strong motivator for recommending home-based care. Additionally, 75% of respondents selected “improve patient’s psychological well-being” as a strong or very strong motivator.

Study authors asked respondents to consider how certain they would be about referring a patient to home-based alternatives to hospitalization based on the patient’s medical condition. “Recognizing there is always EP discretion in evaluating any patient, the question was worded to allow respondents to include more general considerations of appropriateness and safety when identifying diagnoses. The question was also worded to limit their consideration to low-acuity patients without life-threatening conditions.”

The most commonly cited medical condition for referral to home-based care was cellulitis, with 62% of respondents providing a “very certain” response. Moreover, “very certain” responses were provided by 56% of respondents for urinary tract infection, 52% for diabetes, and 34% for community-acquired pneumonia. Physicians were “least certain” about considering patents with heart failure for care at home.

“The key takeaway of the study is that there is the potential to reduce hospital admissions if there were appropriate pathways established, which could allow more patients to be cared for appropriately in the comfort of their own home,” Castillo concluded. “The majority of ED physicians we surveyed believed that home-based care could be a better setting to care for low-acuity chronic conditions or acute disease exacerbations, which could help maintain or improve the patient’s psychological well-being.”

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