Emergency Room Care at Home

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Hospital emergency departments (EDs) were initially designed to provide immediate care for patients experiencing acute medical conditions and serious trauma victims. Once patients were stabilized they were either discharged home or transferred to another location for more advanced and specialized care. Now, EDs are experiencing increased use by people who do not have a primary care provider and use the ED for routine medical care. The increased inappropriate usage of the ED places an increased stress on already strained healthcare resources.

EDs have responded to the increased usage for non-emergent services by offering many more resources than the original emergency room. Now the ED has more diagnostic and treatment options than were previously intended. The ED now is a self-sufficient unit within the larger medical center, and has become integrated into the patients’ continuum of care. In-house specialty consultations are usually immediately available as are advanced diagnostic studies. This has perhaps led to a perpetuation of the misuse of the modern day emergency department.

An increasing problem is the misuse of emergency services by patients who do not have a primary care provider and use the ED for routine and non-urgent care. Less than 10% of emergency room visits are actually emergencies. More than half of the patients that present to the ED could be better served by being treated in place (home, skilled nursing facility, occupational health office, or added on to a PCP schedule). One-third of ED visits could be treated in a Primary Care Provider office. It has been well established treatment in Emergency Departments is more expensive than in any of the above mentioned potential care settings.

Despite the high cost of ED services non-emergent use of emergency services continues to grow. Many non-urgent ED visits could have been avoided if patients had a pre-existing relationship with an accessible primary care provider. In addition to the financial cost, crowded waiting areas, long wait times, actual and potential delays in receiving medical care patients are subjected to increased risk for medical errors, exacerbation of pre-existing conditions, and nosocomial infections. ERs will be swamped in the middle of the flu season with a combination of patient types some with actual flu or swine flu while others have minor sprains. Now the person with the sprain has been exposed to the highly contagious flu.

The medical house call has started to make resurgence in many parts of the country to help address many of the primary preventative non-urgent care needs of patients. The average ED visit in NYC can cost upwards of $800 and brings with it the risks of medical errors due to many different health care providers, loss of work and wages due to prolonged wait times, and infectious disease risk due to the gathering of people with airborne illness (Influenza, H1N1, staph and strep infections).

The average cost of a medical house call in NYC ranges from $150- $600 and greatly reduces the risk of nosocomial infections, saves time and reduces lost wages because the patient is able to wait in the comfort of their own home. Often times being able to see the patients normal environment can provide many clues for diagnosing a condition at a fraction of the cost of the ER visit. One hospital in Connecticut has even gone to posting wait times on line for their ERs so patients can log on and see how long it will take to be seen. As much as policymakers say they would like to reign in cost of health care clearly some have decided if you can’t fix the problem you may as well feature the problem.

The modern day medical house call can now offer many of the same services that were once only available in the emergency room. In the modern day medical house call patients can have comprehensive physical exams that include blood work, EKGs, x-rays, and ultrasounds (cardiac echo, carotid Doppler studies etc). These tests are often sufficient to provide the needed data to make a diagnosis and establish a treatment plan. Another benefit of the medical house call is the clinicians that are seeing you are able to give you their undivided attention. Also you will be able to see the same health care provider as opposed to the doctor of the day or medical resident. Another advantage of the medical house call is the increased privacy that you are afforded by the nature of staying in your home. If patient use the medical house call for their primary care needs as well as their sick day needs they may be able to spare themselves the stress and risks of a trip to the emergency room.

Some common conditions that can be treated in the home include common pulmonary infections (pneumonia & bronchitis), gastrointestinal conditions (stomach flu & abdominal pain), dermatological conditions (2nd degree burns, acne, rashes), chronic conditions (diabetes, COPD, hypothyroid, obesity, congestive heart failure, high blood pressure), urological problems (urinary tract infections, prostate inflammation, kidney stones), and dehydration. One preventative care measure that can be done in the home that is not typically done in an ER or even a traditional doctor’s office is health behavior counseling for lifestyle modifications. Typically this is done in doctor’s offices and Emergency rooms by giving you a generic handout. The reason for this is because the traditional care environment is focused doing the least amount of care possible to meet the needs of the masses that are waiting to be seen.

Emergency rooms were initially designed to treat acute medical conditions and to stabilize trauma patients before they are transfer to the appropriate treatment location. Unfortunately, EDs have also become a place to seek treatment for many people who do not have a primary care provider. As a result, the numbers of emergency visits has increased, although the reasons for the visits are often not emergencies. Non-emergent visits are causing a huge backlog of real emergency patients and increasing the amount of money spent on healthcare.

A new medical house calls company in NYC has recently opened which allows patients to communicate with their PCP online via a secure patient portal. Patients can request appointments online. The Nurse Practitioner arrives at the patient’s home, office or hotel usually the same or next day. The NP can diagnose the problem, order tests (most of which can be done at the patients home) and electronically submit a prescription to the local pharmacy that can typically deliver the medication. The company also offers established patients the convenience of web-cam follow-up appointments and email consultations, which allows patients to take their primary care provider with them when they travel. All of this costs a fraction of what the starting price of an ER visit would be. Patients can use their flex spending and health savings accounts or major credit card to pay for this service. As the debate over health care continues more and more innovative and market solutions will answer the call to solve the nations health crisis. The problem will be if policy is made to stifle innovation.