Uninsured patients requiring prolonged courses of treatment with intravenous antibiotics can be trained to treat themselves at home and achieve outcomes comparable to patients who receive treatment in traditional settings, data shows.
This is the first of a two-part interview. Read part two.
Teaching uninsured patients how to self-administer IV antibiotics for outpatient parenteral antimicrobial therapy (OPAT) has paid off for Parkland Hospital, a safety-net hospital serving Dallas County, Texas.
The program has resulted in similar or better clinical outcomes than healthcare provider-administered OPAT and 47% lower 30-day readmission rates over a four-year period, according to a recent study published by PLOS.
About the program:
The program is for uninsured patients to self-administer antibiotics at home as an alternative to remaining in the hospital or a traditional healthcare setting to complete their therapy. Patients who receive OPAT services are typically those who have been diagnosed in the hospital with an infection that requires a prolonged course of antibiotics.
This is done for more invasive infections, whether it’s osteomyelitis (an infection of the bone) or endocarditis, a heart valve infection, for example.
OPAT has been around since the late 1970s, was initially shown to work in pediatric populations, and then in adult populations. We started this program in 2009. I’m proud to say that Parkland is the first to publish outcomes of doing this kind of model. We don’t know who else is doing something similar to this.
On why Parkland started the program:
We started the OPAT program because we recognized that patients with infections who require long-term antibiotics typically receive concentrated diagnostics and therapeutic services.
The first couple of days is when we’re really busy trying to figure out what’s wrong with the [patients], trying to figure out a diagnosis, getting a treatment plan going—there’s a lot of stuff happening. But once they’re stable—simply because they have no other place to go—safety-net hospitals would simply just absorb that and have them stay in the hospital or discharge them to another setting to receive care, but not home, necessarily.
We talk about healthcare disparities in this country, and see that the patients who are insured have the option to be discharged early to home or to a lower-cost nursing facility to complete their therapy. But unfunded patients don’t typically receive these options and they usually remain in the hospital.
On improving resource utilization:
The United States leads all other developed countries in healthcare expenditures. I think the data says in 2013 we spent almost $3 trillion—that’s almost the entire GDP of France. And yet with all that we spend we don’t necessarily do well with things like resource utilization.
Safety-net hospitals like Parkland are charged with taking care of those who are uninsured. We have a large population of Medicaid and uninsured patients, for example. We find that our emergency room gets full fast, and our hospital gets full fast.
Patients who require six weeks of antibiotics may have stayed in the hospital and received day number 40, day number 41 of antibiotics with the help of a nurse. But they’re occupying a hospital bed.
And when you think about the public health need and the fact that there are many patients that are coming into the emergency room and are acutely ill and need to be seen, from my standpoint, the resource utilization becomes really important.
It’s a public health impact to do this kind of project because it improves the use of resources and opens up the beds for the more acutely ill.
On how the program was developed:
We developed the program as an alternative for uninsured patients to complete long-term therapy at home. But we wanted to make sure that the outcomes these patients received were comparable to services received in traditional settings.
We really worked on bedside teaching and developed a competency assessment tool that was used to test our patients’ abilities multiple times prior to being discharged from the hospital.
Then they were discharged from the hospital into a dedicated post-discharge OPAT clinic that I ran, and they were followed weekly by nurses for their PIC line care.
They go from the hospital with a weekly supply of antibiotics and they come in once a week to our clinic where the nurses take care of their PIC lines and draw routine labs. Then, at fixed intervals, they’ll see me or another infectious disease physician that can figure out how well they’re progressing.
On patient literacy and teaching:
We have a patient population of relatively low literacy when you compare them to say, private hospitals. We don’t have fancy pumps or electronic devices that we’re using. I believe health literacy is the core of this intervention. It’s a relatively cheap intervention.
We developed a multilingual patient education pamphlet at a fourth-grade literacy level. And we employ the teach-back method for bedside teaching. That was also hugely critical. The teach-back method is really encouraged by the Institute of Medicine as a good way to make sure that patients understand what’s going on.
And then we developed a health competency tool. We developed these materials in both English and Spanish.
On making sure patients are prepared to administer antibiotics:
We have [patients], on three separate occasions, go through demonstrations to show us that they can do tasks as simple as saying, ‘I am being treated for an ankle infection of the bone for 6 weeks.’
We ask them how long they’re being treated. Basic things like that they have to be able to tell us to more complex tasks such as making sure that they spike the bag with IV tubing without touching the spikes to anything, and that they squeeze the drip chamber until it’s half full of liquid. You stop and think about these things—drip chambers, spiking, IV tubing—it’s fairly sophisticated.
It takes a little bit of practice and walking them through the steps. And it’s been remarkable to us to see how well they’ve done.
[Patients] receive seven days of antibiotics at a time, and the back of each antibiotic bag has a QR code that patients can scan with their smartphones. The code opens a YouTube video that goes through all the steps; it’s really helped with reinforcing education and troubleshooting.
On patient eligibility and choice:
They go through a screening process. They have to be eligible for the program. [For example,] we don’t send IV drug users home, so if they have a known history of IV drug use, we’re not going to put a line in their arm and send them home. There are criteria that makes them not eligible for our program.
Typically, you have to have reliable means of transportation, access to a refrigerator because of the stability of the drugs, telephone access, and a list of criteria that we look at.
And [the patients] certainly can tell us, if they don’t feel comfortable doing this. It wouldn’t be reasonable to do anything but find alternatives for them, whether that means staying in the hospital, or finding a nursing home that will take them on a charity basis.
On outcomes:
We don’t want to see people coming back into the hospital; we want to know that we did this well the first time. Our patients have 47% lower 30-day readmission rates than the comparison group of patients leaving Parkland with similar demographics.
I think [the success] is ownership of one’s health, tapping into this phenomenon of patient engagement, and patient empowerment.
On what matters to the patient:
Apart from healthcare system outcomes, patient-centered outcomes need to be measured more and reported in our literature. So we’ve engaged in a patient survey. Anecdotally—we haven’t gathered all the data—people have been very satisfied with the program.
Our patients have come back and told me over and over, that what they value is the ability to return to work earlier, take care of their dependents at home, and avoid the high cost of hospitalization by being discharged early.
They certainly show us they can complete therapy safely in the comfort of their home environment with minimal interruption of their daily lives, and that’s huge for them.
Look for second part of this interview which covers the importance of executive support, how the program saved $40 million, how it could be applied to other settings.
Alexandra Wilson Pecci is an editor for HealthLeaders.
