ED staff, paramedics work to reduce readmits
Team develops care plans for at-risk patients
Executive Summary
Duke Raleigh Hospital's emergency department staff and the county's team of advanced practice paramedics work together to prevent readmissions among patients who are high utilizers of the healthcare system.
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Working with Medicaid managed care organizations, the team has developed care plans to help get at-risk patients the right care at the right place.
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The team involves the patients in setting goals and creating the care plans.
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The paramedics assess the home situation and psychosocial needs and alert the hospital's case management staff.
The emergency department staff at Duke Raleigh Hospital has forged a relationship with the Wake County's advanced practice paramedics to improve patient care and reduce readmissions.
"The advanced practice paramedics are our eyes and ears in the patient homes. The emergency department case managers don't always get the complete story about what is going on with patients. The paramedics see firsthand what their home situation is like and what their support system really is," says Denise Gregory, RN, BSN, ACM, team leader, emergency department case managers.
Gregory meets once a month with the advanced practice paramedics and representatives from the area's Medicaid managed care network, which also coordinates care for the aged, blind and disabled, and Medicaid managed care organization for mental health care.
"We discuss cases that we have in common and develop strategies and interventions to help patients get to the right place and the right level of care. When we bring up patients at the meetings, most of the time, everybody at the table is familiar with them. About 80% of the patients are receiving care from everybody," Gregory says.
The group currently has about 35 care plans in place for patients who are at high risk, most of whom are high utilizers of health care with complex conditions and multiple comorbidities.
The care plan includes demographics, past medical history, names of the primary care provider and any specialists treating the patient, what the home situation is like, if a case manager is assigned, and other pertinent information. Patients are involved in setting goals for the plan. "Patients don't want to be in the hospital, but they need help connecting with appropriate services. Sometimes the goal is to link the patient to a specialist with an office in a convenient location or to help them stay pain free. Most of the time, we can link them with specialists or programs that can help them," she says.
Some of the patients have transportation issues that keep them from seeing primary care providers. Others have social needs, but often won't mention them to the hospital staff.
"The advanced practice paramedics get the back story of what is going on at home that the patients are embarrassed to mention. They help us tear down the walls that are contributing to the patients' conditions," she says.
There have been several instances when the paramedics mentioned that the utilities had been turned off in a patient's home. "We were able to get them turned back on, but even though we had conducted an assessment that included social needs, we had no idea the utilities had been turned off until the paramedics told us," she says.
The care plans are uploaded into the Medicaid provider portal so that all hospitals and physician offices have access. "We cover all the bases. Everybody brings something to the table," she says.
When the paramedics get a call about one of the patients in the initiative, they already have their care plan and their destination. "The paramedics call me when they are en route to the hospital and let me know what is happening so the emergency department doctors can be prepared," she says.
Since the advanced practice paramedics are trained to do medical screening in the field, they often don't have to take patients with mental health issues to the emergency department. They can transport them directly to a mental health facility.
They also can assist the emergency department case managers in making sure the patients stay safe in the community. "When there's an elderly person who lives alone or someone with a lot of comorbidities, we can ask the paramedics to check their medication, take their blood pressure, or look for swelling," Gregory says.
The goal of the program is to prevent over-utilization. "One of the goals of the program is to prevent overutilization, but the more important goal is to get patients to the right place, and the emergency department is not always the right place," Gregory says.
