Date Submitted: January 2016
Story Submitted by: Teresa Wall, Captain, Community Paramedic Coordinator
Organization: Johnston County Emergency Medical Services
Location: Johnston County, NC
Community Based Care Transitions Program Utilizing Specially Trained Paramedics
Description of Population Served:
EMS utilizers: Citizens that call 911 requesting an ambulance 4 or more times in a 30 day period. ED utilizers: Consumers that use ED 7 or more times in 6 month period. Discharges. Patients discharged from hospital that were deemed high risk by case management with a diagnosis of COPD, CHF, and diabetes.
Innovative program utilizing specially trained paramedics to perform in-home assessments, education, care coordination, and connect patients to community resources. Our goals are to reduce avoidable readmissions, EMS utilization, and emergency room utilization.
EMS and ED utilizers: There was no program available to assist these patients with care management to prevent the cycle of over utilizing emergency services for non emergent reasons. Discharges: The local hospital was working hard to reduce their readmission rate. The community parramedic program provides care transitions for patients, especially those that were not home bound or do not qualify for home health.
Strategies and Interventions Implemented:
Our goals for all patients in the program are fairly similar. We attempt to make contact with the discharge patient within 24 hours and perform a home visit within 72 hours. A patient stays with our program for approximately 30 days with home visits once a week or more based on patients needs. With all patients a social and safety assessment is performed to identify our problem areas and begin a conversation as to possible solutions. A primary care home is established for every patient and a list of urgent cares in the area with times and available payment options. Medication reconciliation is performed with special attention to blister packaging, home delivery, and affordability. Community resources are offered to patients to aid with transportation, social interaction, healthy food options, faith based services, behavioral health services, and any other need the patient may have.
Our average readmission rate is 13.75% with 22/160 patients readmitting. The frequent EMS and ED utilizations have been cut by more than half when comparing our patients utilizations 6 months pre program to 6 months post program.
The most important research you can do is done when you talk to your patient. Perform a warm hand off to every resource you provide them. Let’s face it if the patient was good at following through then they probably wouldn’t have qualified for the program. Lastly, you can’t do it alone. Build strong connections to your community resources, physicians practices, and the local hospitals.
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