IHD Journal Watch: Paramedics vs. Readmission

Paramedics vs. Readmission

According to CMS, the top three hospital readmission diagnoses are acute myocardial infarctions (AMI), heart failure (HF/CHF) and pneumonia. Regional West Medical Center (RWMC) data reflects that these are also the top three diagnoses for readmission to RWMC. 

An interest exists in finding ways to prevent unnecessary emergency department visits and hospital admissions. Discussions led to an idea for trialing the use of paramedics to do home visits to patients post discharge. The determination made was that the visits needed to focus on health maintenance and teaching. The patient population would focus on those with a diagnosis of heart failure or pneumonia.

On Feb. 14, 2013, Valley Ambulance and RWMC partnered together in a pilot project aimed at just that. Patients were randomly assigned to receive visits from a paramedic or a homecare RN. The outcomes were measured to determine the effectiveness of the health maintenance and teaching model based on readmissions. The readmission outcomes were also compared between those patients receiving visits by a home health RN versus a paramedic.

Medication confusion was the most common problem for patients of both diagnoses in the beginning of the project, but through joint problem solving, this became less of an issue as the project progressed. Simple things like owning a scale to monitor weight were barriers to overcome. Follow-up appointments with primary care providers did not always occur within the first week of discharge; more calls were made to providers on these patients to prevent readmissions. Compliance with follow-up visits to the primary care provider was highest when the patient left the hospital with the appointment already made. 

The pilot project concluded Feb. 14, 2014. The results indicate that health monitoring and teaching post-hospital discharge is beneficial due to the complexity of the heart failure and pneumonia patients. This can be safely provided by paramedics when the right support is available. Examples are a medical director as well as support from primary care providers, nursing leadership and pharmacy leadership. 

The sample size for this pilot project is small due to a variety of reasons. Despite the sample size, the hospital administration, providers and Valley Ambulance leadership all see this as a step in the right direction and believe the work needs to continue. New concepts are already being discussed, such as a primary provider clinic case manager to communicate with the paramedics regarding needs as well as to conduct phone calls to the patients identified at risk after the home visits are concluded. Carrying this concept out to rural communities is also being discussed. 

Traditional models of care are not adequate for patients with complex needs. In rural areas where provider shortages exist and patients often travel 30 miles or up to two hours to see their primary provider, creative solutions need to be explored.

Analysis

Congestive heart failure readmissions are a primary focus for CMS due to the fact that 14% of Medicare beneficiaries have CHF, but it consumes 43% of Medicare spending. This is likely why it’s one of the three initial diagnoses to be monitored for the readmission bonus and penalty program by CMS. The readmission program has brought about aligned incentives for hospitals to work collaboratively with post-acute healthcare providers to improve the hospital-to-home transition to prevent unnecessary readmissions for discharged CHF patients.

One of the current limitations of the healthcare finance system is that not all patients being discharged from the hospital qualify for home health services. In those cases, a coordinated EMS-based mobile integrated healthcare (MIH) program can help achieve similar results for patients who may not otherwise enjoy the benefits of home health services.

Although the cohort is small, this study identifies that a multidisciplinary approach to care transitions that includes specially trained paramedics as part of an MIH program appears to reduce potentially preventable readmissions. We encourage other programs to replicate this study to determine if similar results are reproducible. —Matt Zavadsky

Journal Source

Knodel S. Exploring the use of paramedics to aid in reducing hospital readmissions. Nebraska Medicine, 2014; 13(1): 7–8, 15.

Care Transitions and Cost Reduction

Background—Poorly executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.

Objective—To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).

Design—A quasi-experimental cohort study using consecutive convenience sampling.

Patients—Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.

Intervention—The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and 1–2 phone calls.

Main measures—We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible but not approached (external control group), using propensity score matching to control for baseline differences.

Key results—Compared to matched internal controls (n=321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total healthcare costs ($14,729 vs. $18,779, p = 0.03). The cost avoided per patient receiving the intervention was $3,752 compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.

Conclusions—This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.

Journal Source

Gardner G, Li O, Baier RR, et al. Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge? J Gen Internal Med, 2014 Jun; 29(6): 878–84.