Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Women's College Hospital, Toronto, Ontario, Canada.
PLoS One. 2019 Jan 2;14(1):e0209241. doi: 10.1371/journal.pone.0209241. eCollection 2019.
The management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices.
An interrupted time series design and qualitative interviews were used to evaluate a multifaceted intervention, SCOPE (Seamless Care Optimizing the Patient Experience), offered to solo PCPs whose patients were frequent users of the ED. The intervention featured a navigation hub (nurse, homecare coordinator) to link PCPs with hospital and community resources, a general internist on-call to provide phone advice or urgent assessments, and access to patient results on-line. Continuous quality improvement (QI) strategies were employed to optimize each component of the intervention. The primary outcome was the relative pre-post intervention change in ED visit rate for patients of participating practices compared with that for a propensity-matched control group of physicians over the contemporaneous period. Themes were identified from semi-structured interviews on PCP's experiences and influential factors in their engagement. Twenty-nine physicians agreed to participate and were provided access to the intervention over an 18-month time period. There were a total of 1,525 intervention contacts over the 18-months (average: 50.6±60.8 per PCP). Both intervention and control groups experienced a trend towards lower rates of ED use by their patients over the study time period. The pre-post difference in trend for the intervention group compared to the controls was not significant at 1.4% per year (RR = 1.014; p = 0.59). Several themes were identified from qualitative interviews including: PCPs felt better supported in the care of their patients; they experienced a greater sense of community, and; they were better able to provide shared primary-specialty care.
This multifaceted intervention to support solo PCPs in the management of their complex patients did not result in a reduced rate of ED visits compared to controls, likely related to variable uptake among PCPs. It did however result in more comprehensive and coordinated care for their patients. Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs.
对于资源有限的单一初级保健提供者（PCP）来说，管理复杂、多病共存的患者具有挑战性。干预的主要目标是降低参与实践的患者整体急诊就诊率。
采用中断时间序列设计和定性访谈评估了一项多方面的干预措施，SCOPE（无缝护理优化患者体验），提供给经常使用急诊的患者的单一 PCP。该干预措施的特点是有一个导航中心（护士、家庭护理协调员）将 PCP 与医院和社区资源联系起来，一位普通内科医生随叫随到提供电话咨询或紧急评估，以及在线获取患者结果。采用持续质量改进（QI）策略来优化干预措施的各个组成部分。主要结果是与同期倾向匹配对照组医生相比，参与实践的患者急诊就诊率的干预前后相对变化。从 PCP 经验的半结构化访谈中确定了主题以及影响他们参与的因素。29 名医生同意参与并在 18 个月的时间内获得了干预措施的访问权。在 18 个月的时间内共进行了 1525 次干预接触（平均每位 PCP 50.6±60.8 次）。在研究期间，干预组和对照组患者的急诊就诊率都呈下降趋势。与对照组相比，干预组的趋势差异在每年 1.4%（RR=1.014；p=0.59），差异无统计学意义。定性访谈中确定了几个主题，包括：PCP 感到在照顾患者方面得到了更好的支持；他们体验到了更大的社区感；并且他们能够更好地提供共享的初级专科护理。
与对照组相比，支持单一 PCP 管理其复杂患者的这种多方面干预措施并未导致急诊就诊率降低，这可能与 PCP 的参与程度不同有关。但是，它确实为他们的患者提供了更全面和协调的护理。未来的方向将集中在通过提高易用性、增加提供的服务范围和扩大到更多的 PCP 来提高利用率。
