Mobile Integrated Healthcare, Operations, Patient Care

The Role of CORE Interventions in Improving Health Outcomes and Reducing Acute Care Utilization

Issue 5 and Volume 43.

During home visits with patients, the CORE team aims to increase self-management, reduce acute care utilization and improve clinical outcomes. Photos courtesy Alicia Dinkeldein

During home visits with patients, the CORE team aims to increase self-management, reduce acute care utilization and improve clinical outcomes. Photos courtesy Alicia Dinkeldein


The Community Outreach Resource Efficiency (CORE) program was created in 2012 as a division of Indianapolis (Ind.) Emergency Medical Services (IEMS) in partnership with Eskenazi Health. Since then, CORE has grown, and now has a team of two community paramedics, six community health workers, an EMT and a social worker. By leveraging this diverse and effective combination of expertise, the team can work with individuals who experience a combination of complex medical and social needs.

CORE aims to increase self-management, reduce acute care utilization, and improve clinical outcomes. CORE works alongside healthcare providers, facilitating self-care through a focus on social determinants of health and access to care. The program supports individuals along with their families and caregivers in their everyday environment to navigate the fragmented healthcare system.

Initially, small pilot studies confirmed that EMS over-utilization was driven by the challenges of navigating a complex healthcare system. To help address the challenges our patients were facing, specialized training was provided to develop a community paramedic team that works side by side with social workers, social care coordinators and community health workers.

These teams provide medical treatment in the out of hospital setting, help patients navigate to the most appropriate venue of care, and provide interventions and resources during home visits.

Currently, the program primarily visits patients discharged with specific target diagnoses: heart failure, chronic obstructive pulmonary disorder, pneumonia and acute myocardial infarction. CORE also receives referrals from Indianapolis Metropolitan Police Department (IMPD), Indianapolis Fire Department (IFD), and IEMS. CORE also provides care and resources to the homeless population.

During home visits, the team assesses five social determinants of heath:

1. Ability to perform activities of daily living;

2. Transportation;

3. Financial stability and income;

4. Food security; and

5. Home and living situation.


The assessment helps the team identify the appropriate medical, environmental and educational interventions.

One goal of CORE is to reduce acute care utilization and improve clinical outcomes for patients with complex social and medical backgrounds. To accomplish this, CORE focuses on several key areas, taking a patient- centered approach:

>>Chronic disease education;

>>Identifying social barriers to healthcare;

>>Helping patients overcome obstacles to self-care;

>>Connect patients to the most appropriate healthcare venue; and

>>Reducing acute care utilization while improving health.


The CORE collaborative model leverages a comprehensive initial visit and follow-up visits, as needed. (See Figure 1.) The CORE team assesses and evaluates patients first at the hospital bedside and establishes a relationship.

Once the patient agrees to a home visit, appropriate assessments are performed by a CORE team. The two-person teams include one medical and one social CORE member. That team then determines if the patient needs a follow-up visit.

The CORE team includes community health workers who conduct social assessments during follow-up visits.

Patient Population

CORE targets patients with limited or no access to other resources. These patients come from some of the most vulnerable and socioeconomically disadvantaged populations in Marion County, Ind. The majority of patients cared for by CORE come from Eskenazi Health, a county health system. However, being the only county hospital, Eskenazi Health cares for a disproportionate number of underserved patients throughout the city of Indianapolis.

CORE also engages with communities through the Neighborhood Enhancement Team, a group of local organizations providing resources in the community.

In partnership with the Shepherd Community Center, which serves one of the county’s most impoverished areas, CORE supports an IEMS-embedded paramedic as well as an IMPD police officer to build relationships, with a focus on prevention and health.

Success Stories: Jay & Agnes

Jay’s blood pressure spiked to 180/100 mmHg. During a home visit, the CORE team educated him about the risks of uncontrolled hypertension, which prompted the team to compare his medication orders with what he was taking.

During their conversation, the team discovered that Jay didn’t have any of his medications, and he hadn’t been taking them for months. “He was unaware of what hypertension can do to a person’s cardiovascular system,” said one of the paramedics who worked with him.

“Not only did he not have a clear understanding of how hypertension affects the cardiovascular system, but also did not know how certain medications can lower his blood pressure and help prevent many of the detrimental cardiovascular effects associated with hypertension.”

In addition, Jay couldn’t drive or take public transportation, and he didn’t have a support system of family or friends to help him. As an alternative, CORE suggested a mail-order pharmacy. Jay gave the team permission to reach out to the pharmacy and establish services for him. (See Table 1.)

Table 1: Social and medical interventions performed for Jay

Identified transportation barrier and arranged a means to have medications delivered at home

Referred to mail-order pharmacy and communicated with the nurse on the status

Emphasized education on controlling blood pressure with medicines along with diet changes

Emphasized primary care physician utilization via phone calls and during every home visit

Provided a medication organizer, educated on the medicines, verified and organized medicines

Provided education on smoking cessation

Communicated with pharmacist and a social worker at the hospital


The next day, the pharmacy met with Jay to review his medication list. Within 72 hours of the initial CORE team visit, Jay received his medications. Jay also agreed to follow up visits with the CORE team.

Once he began taking all his medications according to his treatment plan, Jay’s blood pressure was 120/70 mmHg. With his medications coming right to his front door, Jay was far more likely to take them consistently

Through their follow-ups with Jay, the CORE team developed a level of trust and rapport. They’ve helped cultivate change through self-support, disease education and advocacy. Jay is still taking his medications as prescribed and his blood pressure is well-controlled.

At a recent follow up, the team noted that he was still maintaining his blood pressure at 122/84 mmHg. (See Figure 2.)

Agnes, another patient, was referred to the CORE program by a hospital for COPD exacerbation. The CORE team at the initial home visit included a paramedic and social worker. Though Agnes was initially hesitant about assistance from the team, they were able to establish a relationship with her. Eventually agreed to let the CORE paramedic review her medication orders. Respiratory therapy is one of many additional skillsets required of the CORE team, so the paramedic provided instruction to the patient regarding inhaler usage.

After their initial visit, unfortunately, the patient returned to the hospital for COPD exacerbations. Before the next follow-up with Agnes, the CORE team met with a palliative care nurse and physician to discuss how to proceed. (See Table 2.) The team agreed that mail-order pharmacy was a great option, and referred Agnes to the pharmacy that same day.

Table 2: Social and medical interventions performed for Agnes

Provided medication verification and education

Provided chronic disease education focused on blood pressure control

Provided education on smoking cessation

Emphasized PCP utilization

Referred to a mental health agency to help decrease anxiety

Referred to mail-order pharmacy to obtain medications

Provided a medication organizer and organized medications

On a follow-up home visit, the team found that Agnes was having trouble keeping her prescriptions organized. The team performed a complete medication verification and used a medication organizer to prepare two weeks of prescriptions. Currently, she’s engaged with her primary care doctor and has a much better understanding of her medications.

On their most recent visit, the team found her health improved and learned that she was interested in education on smoking cessation. After their initial discussion, Agnes approached her doctor to consider obtaining a nicotine replacement therapy.

The team also recalled that, during the initial home visit, Agnes had a high level of anxiety. After building a relationship with her over several phone calls, it became very evident that one of her biggest barriers to managing her own care was her level of anxiety. To address this, the CORE social worker also developed a care plan for her anxiety, which included multiple follow-up visits.

“She was aware of her anxiety and took prescriptions to assist her with coping, but she was in need of someone to come alongside her and walk her through how to manage her anxiety in a way that would allow her to function in her day to day life,” noted the CORE social worker.

Agnes was enrolled in a local mental health program to provide additional educ tion and therapeutic services for her anxiety. The CORE team believes that she now has all the resources she needs, and knows how to use them effectively.

“This has made a difference not only in her mental/emotional wellbeing, but it has also impacted her physical wellbeing,” the social worker recalled. “She has learned coping mechanisms and breathing techniques that help her stay calm and focus on her needs. Being part of this process and watching her grow as a result of CORE’s involvement has been extremely rewarding.”

In both cases, the CORE team established a strong relationship and trust, allowing them to connect both patients with the most appropriate resources. The interventions increased both patients’ knowledge of their disease and medications, reduced ED readmissions, and removed the barriers to obtaining care. (See Table 3.)

Table 3: Pre- and post-CORE interventions with Agnes




Relative % Change

Number of hospital admissions within 30 days




Number of ED admissions within 30 days




PCP office visits within 30 days




Number hospital admissions within 60 days




Number of ED admissions within 60 days




PCP office visits within 60 days





Programs like CORE have a great potential to improve health through identification of barriers to care and individualized social and medical assessments. The greatest lesson learned is that barriers to care must be investigated individually among targeted patients. Additionally, relationships matter; CORE engages patients through multiple home visits and phone call follow-ups. It’s because of these relationships that CORE will be able to positively impact health outcomes in the long run.

Community paramedicine programs like CORE can improve patient’s knowledge, and are effective in preventing hospital and ED utilization. At present, CORE plays an essential role in bridging healthcare gaps for patients with complex social and medical conditions.

Most importantly, CORE has established strong partnerships with many other local and state level agencies in efforts to connect patients to most appropriate resources.

CORE constantly works to improve processes to effectively improve outcomes, and the program’s successes are a result of its patients, families and caregivers working together building a structure that removes barriers promotes better health.