Canadian emergency departments (EDs) are in crisis, facing overcrowding, record-setting waiting times, and even closure. While having access to a primary care provider (PCP) reduces ED use, one in five Canadians lacks this access and may have no alternative to seeking care in an ED. ED crowding has been associated with poor outcomes, including treatment delays, medication errors, increased admissions, unsatisfactory patient experience, and staff burnout [1]. Redirection of low-acuity ED patients to community-based care is a strategy for reducing crowding that has been shown to be desirable to many patients [2]. Implementation of such a strategy in the context of an overburdened primary care system presents both a challenge and an opportunity to consider models of team-based care and build capacity in the primary care system.

In this issue of CJEM, Leung et al. explore parental willingness to consider redirection to a community-based healthcare provider after presenting to a pediatric ED with a low-acuity condition [3]. They found that most parents would be interested in leaving the pediatric ED in favor of a community healthcare appointment, provided they could see a physician and that the appointment would occur in a timely manner. Families approached for participation were self-referred and presented with mostly acute problems. While the majority (59%) said they would favor a community appointment over the ED if given a choice, many (63%) would only consider the option if the appointment could be same day. There was a greater desire for evening appointments than daytime appointments, and stronger preference for a community appointment among parents of younger children. This study provides an understanding of family preferences and proposes a method to improve both efficiency and resource stewardship.

A crucial aspect of implementing a community-based alternative to an ED visit would be ensuring integration with the local primary care system in a manner consistent with the Patient Medical Home Model. This model, originally developed by the American Academy of Pediatrics, describes care that is accessible, patient-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. The adaptation of the model to the Canadian context places additional emphasis on interprofessional team-based care in the context of a medical neighborhood. Benefits demonstrated in Canada include neutral or positive effects on system cost, greater access to care with reduced waiting time, enhanced coordination, greater patient and provider satisfaction, fewer ED visits, and fewer hospitalizations [4]. An important component of aligning community-based appointments as an alternative to ED visits would be communication and coordination with a patient’s own PCP. In the study by Leung et al., only 28% of parents stated that they would accept a community appointment if the provider were a nurse practitioner. Sixty percent would do so if the provider were a family doctor, and 82% would accept a community appointment with a pediatrician. While reasons for these preferences are not known, it is possible that families would be more accepting of other providers if they were confident that care would be coordinated with their personal doctor. This is a preference that would need to be explored within local context if implementing such a program.

While holding promise as a concept, ED to community redirection alternatives have not been frequently tested. One successful initiative used quality improvement methods to initiative to achieve redirection of 46% of eligible patients with no adverse outcomes [5]. In this initiative, patients were eligible if they were established patients in the participating clinic, presented during daytime hours, and met low-acuity criteria. Upon electronic alert of eligibility, a physician would perform a screening assessment, and the patient and family would be directed to the nearby participating pediatric office. Additional health benefits were noted for redirected patients, including administration of overdue vaccines and well-child checks.

The proposition of offering ED patients a community-based alternative appointment is not without controversy.2 There would be significant ethical issues to consider if such a process were to be made mandatory rather than optional. Furthermore, in most EDs, crowding is more dependent on ability to move patients out of the ED than the volume of patients entering the ED. Finally, it is possible that similar benefit could occur just by increasing same-day or next-day access to PCPs in a medical home setting, without requiring patients to present first to the ED. It is likely that some of the patients in the study by Leung et al. would not have presented to the ED if a community alternative had been available. EDs should not intentionally create short-cuts to accessing care, as this would exacerbate crowding. Some patients seek care in EDs because they do not have their own PCP. To support sustainable decrease in nonurgent ED use, community-based redirection programs should be combined with efforts to connect unattached patients with a PCP in a medical home setting.

Recommendations

  • Implementation of community-based appointments as an alternative to ED visits should be done only with careful measurement of process, outcome, and balancing measures, to ensure benefit and identify potential unintended consequences.

  • Family physicians and medical home operational leads, as well as patients and families, must be included in codesigning programs that offer alternatives to ED care.

  • Health care systems should strive to improve capacity for acute visits in the primary care setting and ensure that families are informed of opportunities to receive acute care within their medical home.

  • Coordination among EDs, PCPs, and sites of urgent visits will be required to avoid fragmentation and inefficiency of care.

  • Programs that redirect ED patients to a community-based appointment should assist unattached patients in connecting with a PCP and medical home.

Leung et al. have demonstrated that offering low-acuity pediatric patients a timely community-based appointment is a family-centered approach that aligns with parent preferences. This strategy has potential for alleviating some of the strain on crowded EDs without compromising safety. By considering the ED to be an important component of a patient’s medical neighborhood, alternatives created to alleviate ED strain can also support the medical home model and play a role in strengthening Canada’s primary care system.