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Paramedicine Program Shrinks Readmissions, ED Use

August 04, 2014

Working closely with patients' caregivers across the continuum, paramedics employed by one North Carolina hospital are succeeding at keeping down readmissions and emergency department use.

Like most hospitals and health system administrators, the leadership at New Hanover Regional Medical Center, a 628-bed teaching hospital in Wilmington, NC, is concerned about the Centers for Medicare & Medicaid Services' reimbursement penalties for excessive 30-day readmissions.

CMS's Hospital Readmission Reductions Program began in October 2012 by penalizing hospitals up to 1% of their Medicare reimbursements for high readmission rates for patients with heart attack, heart failure, and pneumonia.

The stakes are increasing as the maximum financial penalty grows to 3% by fiscal year 2015, and chronic obstructive pulmonary disorder and total hip and knee replacements are added to the list of health conditions included in the calculation.

"We are one of only a couple of providers in North Carolina that hasn't been fined for readmission rates in the last two years, but we are still working hard and fast on not getting a readmissions penalty from CMS," says David Parks, the hospital's vice president cardiac and clinical support.

Reducing Risk of Payment Penalties
As part of its readmission reduction project, New Hanover launched a community paramedicine program in early 2014 in which paramedics work with patients dealing with complications from chronic illness with the goal of providing in-home care whenever possible.

"In 2013, 29% of New Hanover's requests for 9-1-1 services were not emergencies," education coordinator David Glendenning, NREMT-P, says of the organization's motivation to start the paramedicine program. "These were medical situations that could have gone to sites other than the ED for care, or, hopefully, could have been handled in the home."

"Paramedics can do a lot more in their scope of practice than people realize," he adds, noting that the level of care paramedics are authorized to provide varies from state to state.

New Hanover piloted the program in 2013 by having a few paramedics work with a small number of heart failure patients who were frequently hospitalized and had an inordinate amount of ED visits.

"The results were significant," Parks says. "ED utilization on those first few patients dropped 93% and readmissions on those patients dropped 54%. We used those numbers to help justify expanding the program."

"Before the pilot started, one patient was admitted to the hospital five times in five weeks. After beginning to work with the paramedics, the patient was only admitted once in six months," Glendenning adds. "Another patient had 13 ED visits in the six months prior to the intervention and only one ED visit in the six months following."

While the data set was small, Glendenning says, "It obviously spoke volumes because you can imagine the costs tied to these patients. … From the level of cost avoidance, which is a big eyebrow-raiser in healthcare, it was clear this could curb ED visits, admissions, and readmissions."

Based on these early metrics, New Hanover received a $281,000 grant from the Duke Endowment for the program, which it used to hire and train two full-time and one part-time paramedics. The hospital has since received another grant and is currently adding two more paramedics.

Coordinating Care across the Continuum
Working closely with patients' primary care physicians, discharge nurses, home healthcare workers, and case managers, the paramedics try to ensure the best care possible is provided across the continuum. Additionally, a pharmacist is being added to the roster of resources the paramedics have available to them.

"The patients go through that full continuum of care, so it's very important for care givers to coordinate their services and make the continuum as effective as possible," Parks says.

"The paramedic, home health, and PharmD positions are all married under the readmissions reduction project, which falls into my scope of responsibilities, so we have everyone working together with no walls. They all talk to each other on a regular basis about which patient needs what services."

Training for the paramedics includes 100 hours of web-based coursework and 200 hours of education in areas such as nutrition, mental health, social services, cardiovascular medicine, and rehabilitation.

"As part of the training, the paramedics also did rotations where they shadowed a home health employee and shadowed a nurse in the hospital so they could integrate the patients' needs into their services," Parks says, adding that being in tune with the kind of support and assistance patients need in order to regain their health and stay out of the hospital is a critical part of the paramedics' job.

Two areas where patients often need extra counseling and where paramedics can have a major impact are medication reconciliation and nutrition, Glendenning says.

"For example, if the paramedics look in the cabinets of a heart failure patient's home and see nothing but salty food, they can help explain on a level the patient can understand why they shouldn't be buying these things.

Or the patient may have 15 medication bottles gathered up on the counter because no one wants to throw old medications away. The paramedic will clear that up right away by contacting the primary care physician and adjusting or removing medications. It's a win/win for the patient and the doctor."

Preparing to Become an ACO
In addition to being immediately effective in keeping patients out of the ED and hospital, Parks believes the community paramedicine program also ties in perfectly with New Hanover's long-term plans to become an accountable care organization and take on the financial risk of managing the health of populations.

"We don't currently have an ACO to where we save money by preventing the readmission. When the hospital reduces readmissions, we are actually shorting ourselves money," he says.

"However, we are moving toward the environment of the ACO and looking at how we can manage the care of our patients in the most cost-effective way possible, which usually is not in the hospital setting. Having that patient come into the hospital is not optimal if they can be taken care of at home."

Parks adds that because New Hanover is the only tertiary hospital in the region, it is able to fill its beds with referrals from other area providers, which allows it to reduce readmissions of chronically ill patients without seriously affecting its census.

"We are fortunate to be able to manage population health now without negatively impacting our bottom line," he says. "Because of that, we can work hard to help these patients in the right place with the right level of care, and it doesn't hurt our revenue because we are making beds accessible to other hospitals who need to refer patients here."

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