Administration and Leadership, Mobile Integrated Healthcare

How an EMS System in Reno, Nev., Watches Over Post-Discharge Patients to Avoid Costly Readmissions

Issue 3 and Volume 40.

To Donna Meek, it must have seemed like a miracle.

On the night of Jan. 19, 2014, Donna told her husband she wasn’t feeling well. Her stomach was distended and she was nauseated—mostly, she just knew something was seriously wrong. Her husband dialed 9-1-1. The paramedics arrived quickly and the last thing she remembers is one of them asking her if her abdomen was normally so swollen.

Shortly after arriving at the ED just after midnight, Donna went into cardiac arrest. Despite resuscitating her, the hospital staff remained less than optimistic and told her husband she probably wouldn’t survive the night—they suggested he might want to call their priest. She spent several days unconscious and on a ventilator.

Two weeks later, she was leaving the hospital.

“They said, ‘Okay, you’re ready to go home,’” Donna said. “I was so nervous. I was excited to finally be getting home, but I was scared [to be left alone at home].”

But the 64-year-old from Sparks, Nev., wouldn’t be alone at home. Fortunately, her husband and a good friend helped take care of her, with the community health paramedics from Reno’s Regional EMS Authority (REMSA) by their side.

 

The REMSA Program

Two years ago, REMSA, a nonprofit provider of EMS services in Reno and surrounding communities, launched a community health program funded by a Centers for Medicare and Medicaid Services (CMS) Health Care Innovation Award. The $9.8 million grant is funding three programs at REMSA: a 24-hour nurse health line, ambulance transport alternatives, and the community paramedicine program, where community health paramedics aim to reduce frequent 9-1-1 calls and post-discharge readmissions to the hospital by receiving additional training on several topics, including chronic diseases. (See sidebar, “Reno’s Three-Pronged Approach to Mobile Integrated Healthcare,” below.)

Reducing return visits to a hospital seems like an obvious goal for any healthcare system, but wasn’t a priority of many until 2012, when CMS started financially penalizing hospitals for high rates of readmission for certain conditions as part of the Patient Protection and Affordable Care Act of 2010.1

Congestive heart failure (CHF) was one of the first conditions targeted by CMS because of its high prevalence among Medicare patients and the high readmission rates associated with the condition. The cost of heart failure in the United States is estimated to be more than $30 billion, and projected to be more than double that amount by 2030.2 Much of those costs are due to return visits to the hospital. Prior to recent efforts to curb them, rates of 30-day readmissions for Medicare heart failure patients from 2004–2006 were nearly 25%.3

Working closely with hospital discharge planners, REMSA receives referrals for hospitalized CHF patients who are set to return home but whose cardiologists fear are at risk for becoming ill again. The program also takes referrals for patients with chronic obstructive pulmonary disease and myocardial infarctions, and for frequent 9-1-1 callers. Trained community paramedics meet with the patients in the hospital and explain the program, and then visit them at home in the first day or two after discharge.

During the initial visit, the community paramedic tries to ensure the patient understands their discharge instructions and has follow-up appointments with the appropriate physicians. They also assess the patient’s home for safety concerns, discuss their diet and review all of their medications.

The community paramedics return several times over the next 30 days—checking on the patient a few times each week. At each visit, they perform an ECG and check vital signs, much like any prehospital provider would during an emergency call. But these paramedics will also draw blood and measure point-of-care lab values. They’ll also check the patient’s weight, as a slight increase can often be the earliest sign that a CHF patient is retaining fluid.

The goal of the program is to keep enrollees healthy enough to stay out of the hospital, which means controlling their diet and medications, and catching any problems before they cause serious harm. For example, if fluid buildup is discovered early, the community paramedics have a protocol to administer furosemide in the home without transporting the patient. If the patient is dehydrated, they can safely hydrate them and avoid an unnecessary trip to the hospital, while also preventing their condition from further deteriorating.

In the first year of the program, REMSA’s community paramedics enrolled 444 patients and made more than 2,000 home visits. REMSA estimates that during that time, 28 readmissions and 97 ED visits were avoided. The preliminary estimate of total savings is more than half a million dollars in payments ($1.6 million in total charges).

Donna’s Story

Donna’s two-week stay at the hospital following her cardiac arrest last winter wasn’t her first encounter with the healthcare system. Born with congenital heart problems, she’s had four open-heart surgeries and has suffered from heart failure for more than seven years. With the help of friends and family, she’s taken care of herself for a long time and didn’t require someone to read her discharge instructions to her.

But Donna still represented a high risk for readmission due to her significant illness. She’s convinced she would’ve returned to the hospital multiple times had it not been for the community paramedics from REMSA.

“It was that positive reinforcement, because I was so scared and so anxious about everything, and the REMSA [paramedics] kept saying, ‘You’re doing everything right. You’re on track,’” Donna said.

After 30 days, Donna graduated from the program. Unfortunately, a few months later she had to return to the hospital. But for Donna, that only proved to her the impact the program had on her health.

“If the REMSA team could have stayed on a little longer, maybe I would’ve realized that the weight was starting to creep up on me,” she said.

At the moment, the REMSA program is focused on the first 30 days after discharge, because that’s believed to be a critical time for CHF patients—it’s also the duration funded by the grant. They do encourage program graduates like Donna, however, to call the community paramedic at any time with questions rather than waiting and calling 9-1-1 for a REMSA ambulance when the situation worsens.

The availability of the community paramedics is one of the reasons REMSA’s program has received such high patient satisfaction scores. (See Figure 1 below.)

“I never imagined that there were such wonderful professionals to come and visit you like the way the REMSA health team did,” Donna said. “They’re like walking guardian angels. They don’t just walk in, take your vitals, and say, ‘Okay we’ll see you next week.’  They went above and beyond.”

REMSA has received positive feedback from the physician community as well, especially from primary care doctors and cardiologists whose patients they serve. Although the community paramedics adhere to protocols set by their medical director and REMSA, they work closely with doctors’ offices to ensure coordination of care. For busy offices that can’t bring patients in every week for ECGs and blood work, the community health program serves as another set of eyes and ears.

“When I see cardiologists in the hospital, they’re shaking my hand. They’re very appreciative,” Jake Beck, a REMSA community paramedic and clinical development coordinator for the program, said.

Figure 1: Community paramedicine patient satisfaction

Conclusion

Beck, one of eight community paramedics trained to make house calls, also appreciates the chance to practice in a different type of environment and make a long-term impact on a patient’s life.

“When you first see a patient post discharge they’re often sick, confused and really struggle to understand what’s going on with them. Once through the program they tend to have a real ability to manage their disease and understand what steps are needed to be successful,” he said.

Donna is certainly doing just that. She keeps herself on a restricted diet, takes her medications as instructed and makes it to every appointment with her doctors. While it isn’t always easy, the care she’s received from her entire medical team has improved her quality of life and provided needed encouragement. Donna also got to spend Christmas with her son and his family just 11 months after they thought she’d never wake up again.

“When you go into cardiac arrest there’s something that really happens to you,” she said of that early morning more than a year ago. “It’s like nothing before. I was so anxious and scared to come home, and I don’t know what I would’ve done without REMSA.”

References

1. Centers for Medicare and Medicaid Services. (n.d.) Readmissions reduction program. Retrieved Jan. 13, 2015, from www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html.
2. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: A policy statement from the American Heart Association. Circ Heart Fail. 2013;6(3):606–619.
3. Ross JS, Chen J, Lin ZQ,  et al. Recent national trends in readmission rates after heart failure hospitalization. Circ Heart Fail. 2010;3(1):97–103.

 

Sidebar: Reno’s Three-Pronged Approach to Mobile Integrated Healthcare

The community paramedicine program is one part of a three-pronged approach taken by REMSA to find ways to provide the most appropriate and safest care for patients with low-acuity medical conditions at lower overall cost. The other two include a nurse health line and ambulance transport alternatives.

These programs are funded by a Centers for Medicare and Medicaid Services (CMS) Health Care Innovation Award, with the aim to reduce total patient care expenditures by $10.5 million over three years.

Nurse Health Line

The nurse health line promotes a nonemergency number available to all Washoe County (Nev.) residents to provide 24-hour help and information, including assessment, clinical education, triage and referral to healthcare and community services. The line is staffed by nurse navigators who are colocated with the public safety answering point, allowing for seamless transfer between the nurses and 9-1-1 call takers when necessary.

Since its inception in October 2013 through June 2014, the nurse health line experienced a higher-than-anticipated level of calls, averaging 2,000 calls per month, with outcome data showing costly ED visits and ambulance transports avoided.

Community Paramedicine

The community paramedicine program utilizes specially trained community paramedics to improve the transition from hospital to home, with the ultimate goal of reducing hospital readmissions to certain patient populations.

The program focuses on patients discharged from the hospital following myocardial infarctions or with conditions such as congestive heart failure and chronic obstructive pulmonary disease, as well as frequent users of EMS resources. Results show that since it began in June 2013, REMSA’s community paramedics have helped patients safely avoid hospital readmissions while improving care coordination, as well as patient quality of life and satisfaction scores.

“The preliminary results of the community paramedicine program show that the EMS community can play a significant role in helping people improve their quality of life and access to the right level of care when needed,” Brenda Staffan, the director of REMSA’s community health programs, said. “As we continue to validate our data and refine our programs, we expect to see an even greater positive impact on patient care and healthcare costs.”

Ambulance Transport Alternatives

The Ambulance Transport Alternatives initiative allows paramedics to provide alternatives to the hospital ED for 9-1-1 patients after an advanced assessment in the field. This includes transport to urgent care centers and clinics for those with non-emergent medical conditions, to a mental health hospital for psychiatric patients, directly to the detoxification center when appropriate.

While there are still some barriers for the program—including availability and hours of operation for alternate destinations, and patient education and consent—data has shown 550 ED visits were avoided between December 2012 and June 2014 due to alternative transport options.

To learn more about community health programs offered by REMSA, visit www.remsacommunityhealthprograms.com. For more information on the CMS Innovation Center, go to http://innovation.cms.gov.