Michigan emergency physicians are proposing a new health care delivery model that integrates primary care into a rural hospital's emergency department operations, a place that many who need non-emergent care often end up anyway.
The proposal was published this week in the Annals of Emergency Medicine, a journal of the American College of Emergency Physicians or ACEP. It touts the idea that emergency departments in small rural hospitals can serve as "collaborative domains" of both emergency and primary care by embracing the role that they already play in providing primary care and integrating it as an active part of their operations, the authors wrote.
The goal is not to replace the existing outpatient rural safety net that typically includes federally qualified health centers and rural health clinics. Instead, it would work alongside community primary care to boost primary care capacity and address social needs wherever the patient shows up for services. Also, through innovations and a more thorough use of rural facilities, they can achieve financial solvency and survivability.
The authors highlighted a case study from North Carolina to illustrate how the model might operate. Carolinas HealthCare System Anson in Wadesboro had the opportunity to rebuild their hospital and based their approach on a "community-focused care model."
Anson County's population is a prototypical snapshot of rural America, the authors said. It includes 27,000 residents, two-thirds of which are obese. Also, 30 percent have hypertension and 20 percent have heart disease. Nineteen percent don't have insurance. Only 19 percent have a primary care physician while almost 30 percent of patients who show up at the ED could be treated in a primary care setting.
The original hospital also mirrored the struggles of many US rural hospitals. The building was an old, 52-bed hospital with an average daily inpatient volume between 3 and 5 patients.
The final design of the 43,000-square-foot new hospital is built around an ED and primary care clinic that share the same space. There are no walls separating the ED from primary care and all patient rooms are in one bay. The staffing stations are in the middle. The ED operates 24/7 and has 10 beds and one trauma room.
The primary care side has 11 rooms and an additional space for specialists to treat patients on a rotating basis. Their average volume is 2 or 3 inpatients a night, typically staying between 48 to 72 hours, mostly for observation. Acute patients are transported to larger hospitals.
To facilitate patient flow, an ED nurse and a physician assistant screen each patient on arrival to determine what kind of care is needed. The hospital also staffs a patient navigator and uses behavioral health and care coordination services out of their emergency medicine–primary care core.
To address further challenges like missed appointments, the hospitals offer van service for patients to transport them for visits. The service is coordinated through a patient navigator who schedules the rides. Community advocates in schools, churches and workplaces monitor and report on community needs.
"Our model leverages the strengths of a diverse health care workforce and is both provider and patient focused. It acknowledges the fact that a rural ED might be the closest point of contact for rural patients. It illustrates how rural EDs and rural hospitals can be optimized to guide patients to the ideal type of care."