As health care reform continues to unfold and performance-based payment models make more headway, emergency providers are pushing the boundaries beyond what the market has traditionally expected from this field of expertise. The latest example of this is taking place in Indianapolis, where emergency medicine faculty at Indiana University School of Medicine (IUSOM) hope to improve the way asthma is managed in children through the use of a community paramedicine program.
Under the program, dubbed Treat the Streets: Pre-Hospital Pediatric Asthma Intervention Model to Improve Child Health Outcomes, children who have either visited the ED or been admitted to the hospital for asthma will receive home visits by specially trained paramedics who will be empowered to assess for potential triggers in the environment and make any needed referrals for social services or medical follow-up. The idea is to improve outcomes and reduce recidivism among this highly vulnerable population.
There is plenty of room for improvement. Statistics show that nearly 30% of children who have been hospitalized for asthma require readmission to the hospital not long after discharge, and as many as 25% of children who have been treated in the ED for asthma will return to the ED within 30 days for another asthma-related visit. Further, experts say that asthma is one of the leading causes for ED visits among children.
While Treat the Streets is narrowly focused on a single county in Indiana, and it specifically targets asthma-related admissions or ED visits to Riley Hospital for Children in Indianapolis, developers hope to create a model than can effectively be deployed to improve outcomes and cut costs in many other communities across the country.
Consider the home environment
Elizabeth Weinstein, MD, FAAEM, FACEP, FAAP, assistant professor of clinical pediatrics and emergency medicine at IUSOM and deputy medical director of pediatrics at Indianapolis EMS, observes that emergency medicine providers have a vested interested in how the healthcare infrastructure cares for children with asthma. "We are the place where people go when they are having an acute event, so we catch a lot of these kids as they enter the system," she says. "More importantly, we are situated at a place where we can intervene in ways which may prevent them from having relapses or a failure to complete the course of therapy that they need to get better."
Weinstein, who is a co-investigator for Treat the Streets, explains that the approach is based, in part, on years of research on how to make a difference with the pediatric asthma population. "There have been a lot of different interventions to try and reduce the [recidivism] rate, and the ones that seem to have the most impact are those that get into the home and into the environment of the family, and work with the families through the barriers that they have," she explains.
Weinstein emphasizes that it is not just a matter of telling children to take their medicine. Many families struggle to pay for the medicine or to even pick up the medicine regularly at the pharmacy. Learning how to administer the medicine correctly is likewise a challenge in asthma care. "There is also the issue of reducing a child's exposure to triggers, which may include smoking or cockroaches or mold in the home," she says.
Establish a curriculum
Leveraging paramedics or pre-hospital providers in a more proactive community health role is not unique; the approach was developed in Minnesota and has been used in the Western mountain states, explains Andrew Stevens, MD, the principal investigator for Treat the Streets, an assistant professor of emergency medicine, and medical director of paramedic sciences at IUSOM. But he believes this is the first time the approach has been used in an urban setting to address pediatric asthma. "We took what has been a movement in the last five years to use paramedics in a different way, and came up with a novel program that really applied to us here in Indianapolis," he says.
In fact, another community health program that uses paramedics to help prevent readmissions among adult patients with congestive heart failure (CHF) is already ongoing in Indianapolis, so the new program has a ready source of seasoned paramedics who are accustomed to this type of role, says Stevens. Further, since a paramedic training curriculum is already in place for the CHF program, developers have a vehicle they can use to train paramedics for the asthma program.
"What we are doing is adding to the curriculum that we already have for [the CHF] program," says Stevens. While paramedics are already equipped with the training to monitor and treat asthma so that it does not become life threatening, the new content includes aspects of pediatric social work, pediatric public health, pediatric environmental care, and the basics of medicine in pediatric respiratory disease related to asthma. "We have broken [the information] down into a month and a half of a fully enveloped, hands-on curriculum that tries to be all encompassing from all of those different disciplines. It is basically an advanced practice curriculum for [the paramedics]," he adds.
To handle the demands of both the CHF and the asthma programs, three paramedics have been tapped to serve as full-time community medicine paramedics. "The expectation is that this will become part of their career experience, and that it will allow them to do this job while also still functioning as street-level paramedics," says Stevens.
Establish comprehensive home visits
When Treat the Streets debuts, first as a three-month pilot in January of 2014 with full implementation of the program to follow in the spring, any visit by a child to the ED or the hospital for an acute asthma exacerbation will be a trigger for a follow-up home visit by one of the community medicine paramedics. At least initially, the prompt for these visits will be manual, explains Weinstein. "We have people working on this everywhere. We have several people situated with EMS, and several people at Riley Hospital - both in the ED and within the division of pulmonology," she says. "Their social workers are on board, and their nurses are on board, so by the time we launch this out into the community, there will be a streamlined process for manual triggering [of the home visits] as soon as kids are admitted."
The home visits will be put on the calendar before patients leave the hospital, and discharge planners will endeavor to schedule the visits within a few days of the hospital visit. "The intention is that this will be a one-time home visit, that the visit will be comprehensive, and that it will enable the EMS provider to initiate stop-gap measures so that if a child is starting to get sick, he or she can make sure the appropriate medicines are started and that the acute care needs are met," says Weinstein. "But [the intention] is also to identify ongoing issues, and then activate appropriate referrals for continued management and care, so public health nursing might be one thing that is triggered by that home visit."
As part of their training, the paramedics will be equipped with resources that they can tap into for specific problems or issues. For example, if paramedics find that there is a cockroach infestation in the home, they will have a specific number they can call to arrange for removal of that infestation, explains Stevens. Similarly, paramedics can take steps to link families with a primary care provider or a high-risk asthma clinic for follow-up. "They can make decisions, and they have the ability to do any necessary medical interventions or basic pharmacology," he says.
Monitor utilization, qualitative factors
Information gathered during the home visits will go toward the construction of an asthma registry that will provide better insight into the barriers that prevent families from achieving more effective asthma control, says Stevens. In addition, he stresses that investigators will be keeping a close eye on 30-day, 90-day, and one-year readmission metrics. While utilization statistics are most important, investigators will also monitor qualitative measures related to parental and family satisfaction with the intervention, and provider approval as well.
Treat the Streets is being funded with an $899,700 grant that IUSOM's Emergency Medicine Division of Out of Hospital Care received from the U.S. Department of Health and Human Services in Washington, DC. However, Stevens is hopeful that the program will be sustained over the long term with payment reforms that move away from fee-for-service models.
"I feel that with these kinds of programs, hospitals are starting to buy into [the concept] of accountable care organizations and [payment models based on] episodes-of-care," says Stevens.
With the risks posed by bounce-back admissions, programs like Treat the Streets may be viewed as a way to reduce utilization or to identify ongoing risk factors, he says.
Perhaps boosting the program's chances for success is the fact that participating groups are already pretty well integrated, says Stevens. "We have a unique partnership in that the EMS system is part of the city/county government, which is also very intertwined with the [Indiana University] School of Medicine, IU Health, and the county health system."
Andrew Stevens, MD, Assistant Professor, Emergency Medicine, and Medical Director, Paramedic Sciences, Indiana School of Medicine, Indianapolis, IN. E-mail: email@example.com Elizabeth Weinstein, FAAEM, FACEP, FAAP, Assistant Professor, Clinical Pediatrics and Emergency Medicine, Indiana School of Medicine, and Deputy Medical Director, Pediatrics, Indianapolis EMS, Indianapolis, IN. E-mail: firstname.lastname@example.org n