COVID-19 Special Report: Lessons in delivering emergency care in new settings

"In emergency medicine, we’ve always thought of this specialty as being built around an emergency department," said Vituity Healthcare CMO Gregg Miller, MD. "When you show up to work, you go in to an emergency department, you see patients in the emergency department. That is emergency medicine. We’re starting to break free of that constraint where emergency medicine can happen anywhere in a community." (Getty/FG Trade)

Could emergency care be delivered outside the traditional setting of care?

Amid the COVID pandemic, it's been among the biggest questions for Gregg Miller, chief medical officer at Vituity Healthcare which staffs emergency departments across the country. As a practicing emergency room doctor, he's witnessed major shifts in thinking about how — or more importantly, where — care can be delivered.

"In emergency medicine, we’ve always thought of this specialty as being built around an emergency department," Miller said. "When you show up to work, you go in to an emergency department, you see patients in the emergency department. That is emergency medicine. We’re starting to break free of that constraint where emergency medicine can happen anywhere in a community."  

A headshot of Gregg Miller
Gregg Miller, M.D.
(Vituity Healthcare)

Here's a look at what he had to say about the "sea change" he sees happening as providers learn to shift their thinking about delivery settings.

Fierce Healthcare: Where are we at with the pandemic now?

Gregg Miller: I think healthcare workers feel a bit more comfortable that we’re not surrounded at all times by this undetectable deadly virus. It’s out there but it’s still a minority of the patients coming in. Where at the beginning, you see New York and you see Lombardy and Wuhan and think, "Oh my God.That’s next for us." I think people are settling into it more and dealing with these patients and recognizing that most of us will make it through. There have been a few hundred healthcare workers who have died for sure, but it’s not like quite as scary as it once seemed.

FH: How are you seeing emergency medicine break free of the emergency department in the midst of this pandemic?

GM: We’re having emergency medicine physicians getting involved in a virtual front door program, which is like a triage nurse hotline on steroids where care is actually being delivered to patients prior to, and potentially in place of, an emergency department visit. We are also looking at post-discharge after the emergency department. Traditionally, it’s out of sight, out of mind. A patient leaves the ED, they are no longer the ED doctor’s responsibility. They’ve been transitioned to their primary care doctors. But the reality is many patients just can’t make it in to a primary care doctor. They don’t have one. Their primary care doctor doesn’t have capacity to see them for the next few days. …

Now with telehealth, we’re implementing programs where emergency medicine physicians can follow up on those high risk patients. With the new CMS waiver, there are opportunities for reimbursement so you can build a program that pays for a physician or advance provider to follow up on an ED discharge patient to see how they’re doing. These are small pilots. They haven’t been robustly institutionalized.

But I think they’re great examples of the possibilities that are out there to take emergency medicine providers out of the emergency medicine department and insert them more into the community to help deal with emergencies out there. I’m sure what I’m describing is true for every specialty. There’s a way to take us out of environments we’re used to working in and using telehealth put us into new environments to use patients where they’re at.

FH: How else are we seeing the healthcare delivery setting change?

GM: We’ve taken clinicians out of their comfortable workspaces and put them into new work environments. It’s happened in a lot of different ways. We sent docs and advanced providers to New York City to help out there. That’s something that health systems can do is look at how can we take our physicians and our advanced providers and — if they are not being called upon in our local communities — ask how can we engage them and get them to different areas? ... We also have a group of advanced providers who are originally emergency management or hospitalists and advance providers who’ve created a strike team and are working with skilled nursing facilities to help train the staff and support the nursing staff on how to manage COVID in the skilled nursing facilities.

So engaging your inpatient team and pushing them into that outpatient realm is one opportunity for hospitals to look for how they can partner with skilled nursing facilities. The skilled nursing facility story is really the most important story around COVID. These are where the patients are dying. This is where the reservoir is in our community and we need to be doing more.

FH: What would you say is the one change you hope sticks after the pandemic?

GM: The willingness to go out and do something different and engage with patients in a different space than they’re used to engaging. This is a sea change for ER doctors to think we should be diverting patients away from the ER ahead of time. Let’s provide advice over the phone and help them get what they need outside of the emergency department.

The standard line whenever anyone calls into an ED is, we can’t give you advice over the phone. Please come in if you feel like you’re having an emergency condition or call 911. That’s just kind of the pat answer. And now there are a few emergency departments that are willing to experiment with trying to engage that patient. ​

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COVID-19 Special Report: Lessons in delivering emergency care in new settings