According to the Centers for Disease Control and Prevention (CDC), over 5.1 million Americans were being treated for heart failure in 2015.1 In 2012, the Centers for Medicare & Medicaid Services (CMS) began reducing payments to hospitals with increased readmissions for certain chronic conditions, such as heart failure.2 In the first year, CMS collected $280 million dollars from 2,213 hospitals who were penalized for excessive readmission rates.3

In 2019, the Joint Commission will offer an advanced certification in heart failure. The Joint Commission is an independent nonprofit that accredits and certifies hospitals in the United States. This certification will only be available to medical centers that have an outpatient heart failure clinic and are participating in the American Heart Association’s (AHA) Get with the Guidelines: Heart Failure program.4 The AHA’s program focuses on reducing 30-day readmission rates of heart failure patients.5

In 2014, Valley Health System, a community hospital in northern New Jersey implemented a mobile integrated healthcare/community paramedicine (MIH-CP) program. This program is the first of its kind in New Jersey. Since its innovation, other hospitals have developed similar programs that utilize EMTs, paramedics and nurses to evaluate, educate and align patients with the appropriate resources to treat their medical conditions. Although its original intent was prevention of hospital readmissions, the program has since been expanded to treat chronic diseases, provide post-discharge instructions and care to patients, and to refer patients to appropriate community services.

MIH-CP is the provision of medical services to patients in their home by EMTs, paramedics and nurses.6 MIH-CP visits are free to patients. The patient nor the patient’s insurance is ever billed for the service. The hospital provides 100% of the funding for any patient that’s considered to be at risk for readmission. The MIH-CP team consists of an EMT, a paramedic and a nurse. The team travels in a hybrid ambulance and visits patients in their homes within two business days of discharge. A hybrid ambulance has an ambulance crew that responds to emergency 9-1-1 calls, performs hospital to hospital transports, and performs MIH visits. The team is dispatched based on referrals from independently licensed providers, the heart failure transitional care unit, case manager, or social worker. Patients can also be referred multiple times if their condition changes and warrants more visits. Visits are need-based and can be canceled or rescheduled based on the patient’s medical condition.

The team can be dispatched for possible heart failure exacerbations, possible chronic obstructive pulmonary disease (COPD) exacerbations, patient education, wound checks, home safety checks, discharge teaching and medication reconciliation. Heart failure exacerbations are treated with IV furosemide.

Shortly after the MIH-CP team’s arrival, the nurse communicates their assessment of the patient to the provider via cell phone. The patient’s provider can be either a physician or a nurse practitioner who’s caring for the patient. The independently licensed provider can adjust their patient’s medications and treat a heart failure exacerbation with IV furosemide in the patient’s home.

Other interventions can also be done based on the patient’s condition and the team’s assessment. Often the IV medication is enough to alleviate the patient’s symptoms and the patient can remain at home and follow up with their provider as an outpatient. If the heart failure exacerbation isn’t resolved within the visit, the team can transport the patient to the hospital.

The MIH-CP team members don’t need a physician’s order to examine patients in their home. The MIH-CP team obtains clients through referrals from physicians, nurse practitioners, social workers and case managers who are involved in the patients’ care. They typically see patients that didn’t qualify for—or whose insurance company has denied—homecare services.

The MIH team intervenes before emergency services are called and help to reduce readmissions by bringing the ED to their home. Since the service is free, the MIH team can decide how many visits the patient needs. Multiple visits on the same day can be provided if the patient’s condition warrants this level of intervention and follow-up.

Although the nurse is the team member that communicates the patient assessment and receives the telephone order from the provider, the team as whole works together to prevent readmissions. While the nurse is on the phone with the provider, the EMT may be assessing the patient’s fall risk, and/or the paramedic may be setting up the patient’s medications for the week in a pill box.

A Retrospective Look at Readmissions

A retrospective quantitative chart review and statistical analysis was performed to explore an association between heart failure patients treated by MIH-CP and hospital readmission rates.

Heart failure patients’ charts were reviewed during the 2016 calendar year. Heart failure patients’ charts were reviewed regardless of whether or not they were readmitted within 30 days of discharge from the hospital.

The ICD 10 code of I50* for heart failure and the previous ICD 9 code 428* for heart failure was used to identify the charts of interest. Patient demographics collected were gender, race, age, insurance status, marital status and presence of comorbidities.

The sample population consisted of 132 patients; 66 in the control and 66 in the experimental population. The experimental sample consisted of 66 heart failure patients that were treated by the MIH-CP team post hospital discharge. The control population of 66 heart failure patients received usual care post discharge. Patients who received usual care received discharge instructions from a staff nurse before leaving the hospital. Discharge teaching includes education on follow-up appointments, activity, diet and home medications.

A chi-square test was performed to determine the relationship between MIH-CP visits and 30-day hospital readmission rates in heart failure patients. Heart failure patients that were visited by the MIH-CP team were less likely to be readmitted to the hospital within 30 days of discharge, (χ2 (1, N = 132) = 29.21, p = .00, phi = -.49).

Heart failure patients that weren’t visited by the MIH-CP team were 30.3% likely to be readmitted to the hospital within 30 days of discharge. Heart failure patients that were examined by the MIH-CP team were 6.8% likely to be readmitted to the hospital within 30 days of discharge.

The average age was 82 years old. The majority of the patients were insured by Medicare. In 2016, the healthcare system treated 2,278 people for heart failure in both the inpatient and outpatient settings. The average length of stay of a heart failure admission was 5.43 days.

Conclusion

MIH-CP is an emerging modality that can be used to decrease the 30-day readmission rates of heart failure patients. The MIH-CP program treats patients with chronic medical conditions outside of the hospital.

Each MIH-CP team member plays a valuable role in preventing hospital readmissions. Although information in the literature is limited regarding the effectiveness of MIH-CP, this quality improvement project clearly demonstrates that our MIH-CP program was effective in preventing hospital readmissions.

As the healthcare landscape changes, providers must adapt to meet the current market needs. MIH-CP is a great way to bridge the gap between out-of-hospital care, home care, outpatient and inpatient treatment modalities.

Table 1: MIH Visit (yes/no) * Readmitted to Hospital within 30 days of discharge (yes/no) crosstabulation
Table 2: Chi-Square Tests
Table 3: Symmetric Measures

References

1. Centers for Disease Control and Prevention. (Jan. 8, 2019.) Heart failure fact sheet. Retrieved April 15, 2019, from www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm.

2. Centers for Medicare & Medicaid Services. (Jan. 16, 2019.) Readmissions reduction program (HRRP). Retrieved April 15, 2019, from www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html.

3. McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015;131(20):1796–1803.

4. The Joint Commission. (n.d.) Advanced certification in heart failure. Retrieved on April 15, 2019, from www.jointcommission.org/certification/heart_failure.aspx.

5. American Heart Association. (April 16, 2018.) Get with the guidelines—Heart failure overview. Retrieved on April 15, 2019, from www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-heart-failure/get-with-the-guidelines-heart-failure-overview.

6. National Association of Emergency Medical Technicians. (2019.) Mobile integrated healthcare-community paramedicine. Retrieved on April 15, 2019, from www.naemt.org/initiatives/mih-cp.