With readmission rates at an all-time high among Medicare beneficiaries, the North Dallas (Plano) Care Coordination Community Coalition was looking for innovative interventions. Members of the coalition—which includes 17 acute care hospitals and stakeholders in the North Dallas area—wanted to increase accountability for readmissions across the care continuum, engage providers outside their silos, and foster communication and collaboration as a healthcare community.
The TMF Health Quality Institute, an Austin-based nonprofit and CMS’ contracted Quality Innovation Network-Quality Improvement Organization for Arkansas, Missouri, Oklahoma, Texas, and Puerto Rico, worked collaboratively with stakeholders to form the North Dallas Care Coordination Community Coalition with the goal of reducing hospital readmissions.
The coalition determined the barriers to care transition in the community included poor communication between providers, lack of medication reconciliation and patient family support, and the need for more effective patient education. After one hospital shared an outcome of reduced readmissions through referral of patients to a CP program, the Plano Fire-Rescue team was asked to join the coalition and share best practices.
In collaboration with the coalition, Plano Fire-Rescue had performed a SWOT (strengths, weaknesses, opportunities, threats) analysis to assist with strategic deployment of a communitywide CP program.
The SWOT analysis further supported readmission determinants previously identified by the coalition, including lack of communication and care coordination within postacute care; a need for better medication reconciliation and improved education for medications; and addressing indigent healthcare and referral to mental health resources. The coalition determined many patients do not have a primary care physician or ongoing treatment plan, and the CP program could both bridge them to a primary care provider and avoid costs via reduced emergency transports and ER evaluations.
Within the coalition, TMF QIN-QIO and Plano Fire-Rescue teams shared intervention strategies and resources such as zone tools, a resource for patients to easily recognize if they’re safe with their symptoms or need to notify their provider or physician. After several collaborative meetings, including consultation with the MedStar Mobile Healthcare team from Fort Worth, the CP program team presented a home-visit intervention it could deploy in the community. The coalition agreed to support the CP intervention via patient referral from member hospitals as long as medication reconciliation, home safety education, and patient education resources were provided as needed.
With the purpose of bridging the gap between primary care and EMS, the CP program expanded the paramedic’s role to involve in-home patient visits and referrals to community-based services. Outcome goals included lowering hospital admissions and readmissions among a targeted group of patients who utilized EMS services frequently for nonemerent situations (the high-utilizer group, or HUG). These goals were based on nearly 1,200 9-1-1 calls made by 200 HUG patients in the Plano area during 2015.
Patients referred to the program were those identified as needing follow-up but nonemergent care. Within the hospitals patients were assessed utilizing a risk-assessment tool similar to the LACE tool (a popular scoring index used for CHF patients), built into the hospital’s electronic health system and supported by community partners. Those patients who 1) had CHF, 2) had multiple admissions, 3) didn’t qualify for home health nursing, 4) lived in Plano, and 5) were vetted by navigators at the hospital were referred to the CP program. Both skilled nursing facility/assisted-living facility care and postdischarge rehabilitation were allowed in the inclusion criteria. Excluded were patients living outside the referenced zip code or in kidney failure and receiving dialysis.
Once identified by a member of the hospital team as qualifying, patients were introduced to the program by the paramedic or care manager using a “warm handoff” approach in the hospital. They shared information and obtained consent. Each patient was offered a home visit and/or referral and coordination of community-based services. If a patient was not able to meet with the paramedic in the hospital, staff explained the program, shared information, and had the patient sign an agreement.
EMS House Calls
In the CP program, the paramedic makes the first home visit within 48 hours of discharge. During the visit paramedics isolate all medications. These are identified and reconciled for duplication, with education provided on everything prescribed. They check expiration dates and conduct some pill counts to make sure the patient is taking their meds appropriately. They also provide counseling on discharge instructions and make referrals to community services.
Depending on patient needs, the paramedic performs any combination of the following activities during a home visit:
Assists in filling prescriptions, sorting medications, and explaining how to take them as prescribed (using teachback medication cards as appropriate);
Provides counseling on hospital and clinic discharge instructions;
Provides disease management, including review of the disease process; utilizes zone tools for reporting symptoms; ensures PCP will follow up (zone tools educate patients about red flags to report to their provider);
Performs nutritional assessments with referral to Meals on Wheels if necessary;
Discusses fall prevention with referral to community program Matter of Balance if necessary;
Activates a comprehensive home safety checklist (assessing lighting, sidewalks, phone accessibility, emergency numbers, trip hazards, fire extinguishers, smoke alarms, items within reach without using ladders, heaters, and emergency medical information).
The paramedic concludes the home visit by either making or following up with referrals to needed services. Of the patients seen, 70% had their medical issues resolved on site, and the rest received continued support and care coordination for up to 90 days.
“On paper the program is 90 days, but this depends on the situation each patient is experiencing,” says Joshua Clouse, Plano Fire-Rescue’s community paramedicine coordinator. “It starts with a minimum of once-a-week visits for evaluation, education, and referrals. Once they’re managing on their own with a dedicated out-of-hospital healthcare team, they are discharged. They are also educated on the after-hours and urgent-condition processes.”
During the initial pilot in 2015, 61 patients were identified and enrolled by coalition hospitals. The majority were Medicare beneficiaries, with an average age of 77, mostly seen in the home setting.
As determined by September 2016 reconciled fee-for-service claims, the annual hospital admission rate in the North Dallas (Plano) area per 1,000 beneficiaries showed a statistically significant reduction from 242.62 at the beginning of the project to 236.69 by its end. This was a relative improvement of 2.4% and translates to an estimated 698 fewer hospital admissions per year.
Other cost savings included:
Ambulance transport: $419 average cost; $27,459 expenditure savings
Hospital ED visit savings: $969 average cost; $77,298 expenditure savings
All-cause hospital admission: $10,500 average cost; $715,875 expenditure savings.
“We’re finding through these programs that we can do more for our patients than just schlep them all to the emergency room,” says Matt Zavadsky, MS-HSA, NREMT, of Fort Worth’s MedStar Mobile Healthcare, who participated in the coalition and consulted for the CP program. “It’s improved the patient’s experience in ways we never imagined while dramatically saving healthcare expenditures.”
Hospital participation in the CP program expanded from one to five in the North Dallas community during this project. Interest has also spread to the pharmacy department at one hospital: After much collaboration the facility was able to provide medication planners for the paramedics to use in medication education.
For EMS units looking to offer these programs, critical components are identifying community needs and the services available to address patients' social needs, and forging relationships between community stakeholders and EMS. Payment is also critical. In Texas some hospitals will reimburse EMS services under a contracted fee; however, this arrangement may not prove sustainable. Other CP programs either partner with or are licensed as home health agencies and paid under the home healthcare model.
“Many patients within our target population routinely call 9-1-1 to be evaluated but aren’t transported,” says Clouse. “Under the current CMS pay schedule, those providers won’t be paid, even though they’ve incurred a significant expense. By not transporting the patient, on average, $3,500 in unnecessary emergency room expenses would be saved.”
By partnering with community stakeholders, the reach and impact of community paramedicine can continue to improve health outcomes.
Kristine “Kris” S. Calderon, PhD, CHES, is senior innovative strategist and researcher for the TMF Health Quality Institute.
Donna Zimmerman, RN, BSN, is a quality improvement consultant with the TMF Health Quality Institute.
Joshua Clouse, BSBM, CP-C, Lic-P, is a firefighter-paramedic with Plano Fire-Rescue and coordinates the department’s community paramedicine program.
Matt Zavadsky, MS-HSA, EMT, is chief strategic integration officer for MedStar Mobile Healthcare.
Michelle Stehling, RD, LD, is health services consultant-II with the TMF Health Quality Institute.