In a large study published in the Canadian Medical Association Journal in April 2018, investigators found that patients receiving home care nursing visits were more likely to go to the emergency room after 5 pm on the day of a nursing visit than they would have been had there not been a home visit.

The study’s findings challenge the notion that home nursing visits reduce emergency room visits, as has been demonstrated for home visits for palliative care. Other studies showed no positive or negative effect of home nursing visits on use of emergency services. More likely than not, the Canadian study will help focus the efforts of home care providers on the aspects of care that really do reduce emergency room visits.

What the study showed

The Canadian investigators looked at two groups of patients in suburban Ontario, those receiving nursing services for long periods of time and those receiving services for short periods. The “long-stay” group was composed of mostly frail elderly people with complex medical issues. The “short-stay” group included patients who tended to be younger than those in the long-stay group. These patients had usually undergone surgical procedures and required nursing services during their convalescence. Both groups received publicly-funded home care nursing visits.

Patients in both the long-stay and short-stay groups were more likely to visit the emergency room after 5 pm on the same day as a nursing visit. The association was stronger for less-acute emergency room visits. The effect was specific to nursing visits: there was no increased association of visiting the emergency room on the same day as a visit from occupational therapists, speech and language therapists or social workers.

It is important to point out that the increased number of emergency visits did not result in an increased number of readmissions, a metric that is very important in healthcare. Furthermore, the study did not ask whether the patients in the study had greater or fewer ER visits overall than did patients without home nursing care.  Finally, the study was not designed to measure the number of home visits that were specifically requested by the patient on the day of the emergency visit. It could be that worsening conditions on the part of the patient could have occasioned the home visit by the nurse.

Digging Deeper

The study’s lead author, Dr. Andrew Costa, observed that the results should not be all that surprising. According to Dr. Costa, home care nurses, at least in Canada, are not “given the latitude within their rules” to manage acute problems they discover in the context of a home visit. Nurses based in the Canadian suburbs might not have access to primary care teams or they may be limited in terms of the scope of their practice.

Dr. Costa did not suggest that the home care nurses were responsible for the emergency visits. In fact, the reasons for the emergency visits varied widely, and no diagnosis predominated according to the data reported by Costa’s group. In the short-stay group (the younger cohort, representing mostly post-surgery patients) the leading discharge diagnosis from the emergency room was “Other Medical Care”, a catch-all expression that does not correspond to typical post-surgical complications, such as urinary tract infections or pneumonia. This mysterious category may point to an opportunity that may be leveraged by home care nurses and their teams.

Failure to Cope

In a companion editorial, Dr. Allan Detsky commented that the study’s findings were “disappointing but not unexpected and serve to remind us that patients who require home-based care are complex.” Among these complexities are the troubling social problems suffered by many recipients of home nursing services.

A particularly difficult problem identified by Dr. Detsky is what he referred to as ‘failure to cope’, a medical-sounding term that refers to the despair that often drives patients to the emergency room. “We must all remember that social problems are real problems and that those with ‘failure to cope’ require compassionate and thoughtful care just as every other patient does”, Dr. Detsky observed. It is possible that the complex web of psychological responses to illness were stirred up by interactions with the home care nurse, not by anything the nurse said or did.

An opportunity

The findings of the Canadian study are not necessarily generalizable to nursing home visits in the US or other countries. Funding opportunities from the US Centers for Medicare and Medicaid are opening avenues for integrated home-based services that may reduce the need for emergency services. In the UK, the National Health Services has made integrated, holistic provision of home services a priority since 2014.

To the extent that American home-based patients are susceptible to the same ‘failure to cope’ as Canadian patients, a lesson we can learn from the Ontario study is that patients’ social needs should be an area of focus in the context of nursing home visits.

According to Dr. Costa, “The big takeaway (of the study) is that we have some work to do in community and primary care around meeting the needs for frail, older adults in their homes.”