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By Liora Engel-Smith
In an election year where soaring health care costs are on voters’ minds, a new collaboration aims to help rural cardiac patients avoid a potentially unnecessary — and costly — trip to the emergency department.
The $1.2 million program, slated to begin in mountainous Wilkes County early next year, will bring doctors and nurses to the scene of medical emergencies through telehealth. The doctors and nurses — most of them experts in emergency medicine — will help first responders evaluate patients with chest pain to decide the most appropriate next step, be it a hospital visit or a trip to a county health department for further tests.
“It’s going to save the patients and the health care system a lot of costs,” said Simon Mahler, professor of emergency medicine at Wake Forest Baptist, which also oversees the program. “[We’ll be] able to help at each level — the hospital, EMS and the health department to make those decisions on where patients receive treatment.”
Mahler hopes the program will serve as a blueprint for similar initiatives for cardiac patients in other rural corners of North Carolina. Heart attacks, strokes and other cardiovascular diseases — the state’s leading causes of death — affect and kill rural residents far more often than their urban counterparts. That trend holds true in Wilkes, a county of 68,000 people where heart disease, the leading cause of death, accounted for almost 900 deaths from 2012 to 2016.
In other parts of the state, notably eastern North Carolina, cardiovascular death rates are even higher.
“This is probably the beginning of a really new way for how we care for patients,” said David Zhao, chief of cardiovascular medicine at Wake Forest Baptist Health, based in nearby Forsyth County. “If you look at other industries, they all changed dramatically compared to 20 years ago, yet medicine is stuck in 20 years ago in terms of how we deliver care.”
Coronavirus has made both providers and patients more comfortable with telehealth, he added, to the benefit of underserved rural areas like Wilkes County. But it isn’t the first time Wake Forest Baptist has made use of telehealth to bring experts to rural areas. In 2009, the health system, which recently joined Atrium, created a telestroke program to bridge similar service gaps in rural hospitals where experts are in short supply.
As in other rural counties in the state, Wilkes has a small regional hospital with an emergency department and limited advanced care. Patients who need more specialized care are often taken out-of-county to a larger facility, in this case Wake Forest Baptist’s main hub in Winston-Salem, roughly an hour’s drive east. So when a patient calls 911 with chest pain, they really have three options, each with its own drawback. They could go to the local hospital that might not be able to care for them, be transported to a larger — more costly — hospital out of the county, or refuse transport altogether.
The best option isn’t always clear, even to professionals. Chest pain can be difficult to pin down in some patients, said Bryant Reid, operations officer at Wilkes County EMS, where first responders see roughly 600 to 800 such patients a year. It isn’t so much about the clear cases, where a patient is in obvious distress and the cause is clear and needs transport to a facility right away, he said. Many cases are hard to assess, he said. Perhaps a patient is in obvious discomfort but their electrocardiogram, or maybe their EKG is just slightly out of kilter and requires additional follow-up, perhaps at a doctor’s office.
Traditionally, first responders have few options with such patients, particularly when a patient refuses transport to a hospital. The collaboration with Wake Forest Baptist not only trains first responders on new evaluation tools, but it allows them to consult with emergency medicine providers electronically on murky cases. It gives non-critical patients another option: transport to the health department, rather than to the hospital.
“If we can do a better job [assessing patients earlier on] then we can get a patient to a more definitive location faster,” he said. “And if we can get them there faster and to the right location, patient outcomes are going to be better.”
An alternative to the hospital
Federal law dictates that paramedics and EMTs can’t transport patients to a clinic that isn’t inside a hospital, but relaxed regulations enacted because of coronavirus allows emergency services to transport people to places other than a hospital, Mahler said. Once those provisions expire, he added, that piece of the puzzle will have to be worked out, either through grants or by other means for the program to be sustainable.
Patients will also pay a small fee for the telehealth service, he added, but if they end up going to the health department or local community health center, rather than to the hospital, they could avoid a costly medical bill while still getting medical attention.
It’s hard to gauge exactly how much money patients might save because the out-of-pocket costs of emergency department visits depend on the type of tests and whether the patient has health insurance. A survey conducted by UnitedHealth Group, the parent company of insurer United Healthcare, found that an emergency department visit costs upward of $2,000 in 2018. In contrast, the company calculated that urgent care visits and doctor’s offices cost less than a tenth that amount.
At the health department, which already cares for roughly 4,500 patients annually as a federally qualified health center, medical professionals can evaluate the non-critical patients in a similar way to an urgent care facility, performing a few targeted diagnostic tests to detect possible heart disease. Not every county health department in North Carolina has this capability.
“If those folks come here, maybe we catch something early so we can kind of head off those further, more advanced heart issues,” said Chad Shore, chief operating officer at Wilkes Health, the clinic that’s also part of the health department.
Shore estimates the clinic will end up seeing one or two non-critical patients from the program each week. The patients themselves will have averted a costly trip to the emergency department and will have an opportunity to get matched with a primary care provider at the clinic if they don’t already have one.
Over time, the health department hopes to see fewer deaths from heart disease and better outcomes for the patients they do see.
Contending with rural realities
Similar to other rural counties, some corners of Wilkes lack broadband access, Reid said, a potential barrier to electronic consultations that neither Wake Forest Baptist nor Wilkes EMS can resolve on their own. Though ambulances are wired with hotspots, Shore said the signal is weak to nonexistent in some pockets in the county.
Reid, from Wilkes EMS, has thought of a workaround. The paramedic team will evaluate the patient and start transport until they return to an area of better reception and can do the telehealth evaluation.
“We’ve got 757 square miles [in the county] so [the ambulance staff] has a little room to go before they need to make a decision on the actual destination,” he said.
The benefits to patients and the region, he said, go beyond medical expertise and cost of care. Wilkes is a sparsely populated county that’s covered by six or seven ambulances per shift. Whenever an ambulance leaves the county to transport a patient to a larger facility, there are fewer trucks available for other emergencies.
“If we lose a truck, it’s about two and a half to three hours turnaround [trip] to Baptist [in Winston-Salem]. We may need those two paramedics and truck to take care of other needs in the county,” he added.
“If it’s needed — it’s needed — and we’re there, but if we don’t need to go there, then that’s a waste of resources.”