Patients who received home care visits from nurses were more likely to visit the emergency department during the evening on the same day, particularly for non-urgent issues, according to new research from McMaster University.

“An emergency department visit is not necessarily a negative outcome, but may be if a frail patient could more appropriately be treated by their usual community-based providers who know them best,” said Andrew Costa, an assistant professor of the Department of Health Research Methods, Evidence, and Impact, who led the study.

Compared with younger people, frail older adults visit the emergency department more often, have longer stays, more misdiagnoses, and are more likely to be admitted to hospital.

“There have been concerns that — while striving for more efficiency — home care has evolved to be task-focused with less full-scope, comprehensive practice that could be integrated with more responsive primary care,” said Costa, who also holds the Schlegel Chair in Clinical Epidemiology and Aging.

The study has been published in CMAJ (Canadian Medical Association Journal).

The research was conducted in the Hamilton–Niagara–Haldimand–Brant region, which has the largest number of adults older than age 65 in the province.

Researchers used home care billing records for 2015 to determine which home care services a patient received, and then linked those data to emergency department records to determine if a patient visited the same day after 5 p.m.

They found that patients who received home care visits from a nurse were more likely to visit the emergency department. The likelihood was greater among people who were not admitted to hospital or who had non-urgent scores for severity of illness that brought them to hospital.

“It’s difficult to determine the appropriateness of an emergency department visit, but we found stronger associations with less acute emergency visits,” said Aaron Jones, a McMaster PhD student and first author of the paper. “This suggests that some patients likely could have received care in less acute settings if it was available.”

In a related commentary, Allan Detsky of the University of Toronto and coauthors wrote, “These findings are disappointing but not unexpected, and serve to remind us that patients who require home-based care are complex. When community-based nurses are neither integrated into primary care teams nor equipped with resources to manage patients’ problems effectively — perhaps by a limited scope of practice — patients have nowhere else to go but the emergency department.”