A Better Way to Care for Long-Term Care Residents in Times of Medical Urgency: An Implementation Intervention Using a Stepped-Wedge Design to Reduce Unnecessary Acute Care Transfers

Abstract

Objective: Approximately 25% of long-term care (LTC) residents are transferred to an emergency department (ED) when experiencing an acute change in health status. This can place strain on health care resources and negatively impact residents. Many residents' conditions could be managed within LTC if appropriate supports were provided. This implementation study objective was to optimize and evaluate processes followed when considering acute care management and transfer decisions for residents in LTC.

Design: A randomized stepped-wedge design was used to implement a standardized LTC-to-ED care and referral pathway, supported by 2 INTERACT tools. The pathway was implemented within 9 cohorts of (4-5) LTC facilities every 3 months, supported by an implementation coach. Implementation strategies considered local LTC context and barriers, as well as pandemic-related challenges.

Setting and participants: 40 LTC facilities and 4 EDs within Calgary, Canada.

Methods: The primary outcome was change in transfers from LTC to ED; secondary outcomes included hospital admissions, use of facilitated telephone consultation between LTC and ED physicians, and community paramedic visits. Analysis used negative binomial regression to estimate the incident rate (per 1000 residents), while adjusting for the different cohorts. An economic evaluation was conducted using a unit cost analysis.

Results: A reduction in the incident rate of LTC-to-ED transfers was observed with the intervention (1.70 postintervention vs 1.91 preintervention; P < .001), along with reduction in hospital admission (0.94 vs 1.08; P < .001). There was an increase in use of facilitated telephone consultations between MDs but no increase in community paramedic visits. The intervention saved the health care system CAD$7.9 million over the postimplementation evaluation period.

Conclusion and implications: Implementation of a standardized LTC-to-ED care and referral pathway appears to reduce ED transfers and hospitalizations among LTC residents, while realizing cost savings to the health care system. Reducing unnecessary transfers from LTC to ED, and instead focusing on earlier identification and management of acute medical issues within LTC, looks to be a feasible, patient-centered, and resource-optimized approach to care.

Keywords: Long-term care transfers; acute care management; knowledge implementation.