Faced with providing services for an increasing population, many of whom are 65 and over, health services internationally are struggling to manage the rising demand for healthcare provision in a context of limited resources and financial hardship.
The researchers behind this Baltimore based pilot study recognized that frequent users of the Emergency Medical System (EMS) further exacerbate pressure on an already fiscally stressed system. The research aimed to determine if early identifcation and focused pre-hospital case management of these individuals reduces the number of required EMS transport and non-transport responses.
This study identifed 25 individuals who most often activated the EMS during the fiscal year 2007. Of these 25 people, only 10 were included in the research because, at the time of the case management intervention, the others were either deceased (n=5), incarcerated (n=2), hospitalized (n=2), residing outside the city limits (n=2), or unable to be located (n=4).
The age range of the 10 participants was between 39 and 89 years, with an average age of 60 years. There were four males and six females; 70% had a mental health and/ or substance abuse diagnosis; and all of the participants had two or more chronic health problems for example, diabetes, hypertension, or heart failure.
Participants were allocated a dedicated case manager for the intervention period from May to August 2008. After an initial home-based assessment of their medical, psychosocial and insurance needs, an individualized care plan was developed for each participant.
The length of intervention varied between 5 to 12 weeks, and, once enrolled in the study, the participants received weekly case management visits. Participants were educated on appropriate EMS usage and provided with a healthcare access telephone number in case they had any health related problems or questions.
During the intervention period, the case manager made a total of 32 referrals to 22 separate agencies including medical, social, and psychiatric services, with the researchers reporting a near 100% compliance and attendance rate by the participants.
Findings show that during the case management intervention period, transport responses for these known, high frequency users decreased by 32% in comparison with the predicted transport responses for this period; and non-transport responses decreased by 79% against previously predicted responses. However, the reader needs to be aware that there was limited data available to assess how the intervention impacted on non-transport responses and this has been identified as a limitation of the study. Predicted usage was based on the analysis of each participant's use of the EMS in the previous year, but there was no adjustment for seasonal trends which the authors also identify as a notable limitation.
The study incorporates a simple cost analysis, and even after the inclusion of the case manager's salary, there appeared to be a net saving to the total health care system during the case management intervention period.
While this interesting pilot study topically highlights possible methods for improved life quality and health economy it is somewhat limited by its specific demographic focus and small sample size, along with an obvious lack of post intervention data.
However, the findings do highlight an exciting area for future research and the authors conclude by recommending further investigation utilizing this approach of interventional case management.