Value-based care of older people

Maaret Castrén, Lauri Mäki

Long-term residential care facility (LTRCF) residents are often transferred to emergency departments due to relatively minor health problems that could be treated in the facility. These transfers are burdensome for the residents and often lead to adverse effects. Older adults living in nursing homes or receiving long-term home care are in higher risk of losing their daily functional capacities or dying after hospital care compared to independently living older adults. Emergency department (ED) visits have been linked to delirium, hospital-related infections, medication errors and information errors. Besides patient-related harms ED visits and especially hospitalizations cause waste in terms of overproduction – unplanned transfers reserve beds in nursing homes and hospitals. Relatives/proxies tolerance for the patient not going to ED was lower than personnels and patients.

LiiSa (an acute outreach service unit “mobile hospital”, in Finnish, liikkuva sairaala, hence the acronym LiiSa)  is a new operator providing acute care for long-term residential care facility residents, treating non-life-threatening exacerbations of chronic illnesses and new injuries or illnesses of the residents on site, instead of transferring them to the ED. LiiSa started operating in March 2019. It operates among 40 public long-term residential care facilities with 1366 residents in Espoo and Kauniainen, two cities with a total of about 300 000 inhabitants.

LiiSa was established to deliver value-based healthcare for older people living in LTRCFs. Value in health care is defined as the measured improvement in health outcomes for the cost of achieving that improvement. LiiSa takes calls from LTRCFs, gives advice, and treats patients in their homes 24/7. LiiSa has the ability to perform simple procedures, such as changing a suprapubic catheter. The LiiSa vehicle is built on a sports utility vehicle base and equipped with a wide range of medications, i-STAT, CRP and basic urinalysis equipment. Experienced registered nurses from Espoo Home Hospital work within LiiSa one at a time. These nurses can consult either nursing home doctors, Home Hospital doctors, or ED doctors, depending on the time of the day. LiiSa does not transport patients. The health outcomes that LiiSa intends to achieve are reduced adverse effects of LTRCF residents due to unnecessary transports to ED, and better treatment outcomes of acute injuries and illnesses due to patients receiving care faster. Another goal is to avoid overcrowding of the ED, as well as to reduce the burden on emergency medical services (EMSs) by taking care of minor urgency emergency treatment, permitting EMSs to concentrate on more urgent, true emergency missions. These factors also lead to reduced costs.

The number of EMS visits carried out in the 40 long-term residential care facilities decreased by 17% after the activities of LiiSa began. This was due to the decreasing number of non-urgent missions. Changes in the numbers of urgent missions were not statistically significant. The fact that the number of urgent visits was not affected, suggests that residents with true emergencies received care by EMSs and, hence, that patient safety was not compromised. These results indicate that LiiSa has the ability of delivering better value care by avoiding burdensome transfers of frail long-term residential care facility residents to emergency departments. By carrying out non-urgent missions that were previously carried out by EMSs, LiiSa allows EMSs to concentrate their scarce resources on more urgent emergency admissions without compromising patient safety. However, there were further missions carried out by EMSs that could have been carried out by LiiSa. Education of the facilities are needed to avoid all unnecessary calls to EMS and all unnecessary transports to the ED.

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