By Dorothy Brooks
Chicago-based Medical Home Network (MHN) is partnering with community paramedics at the Chicago Fire Department on a program aimed at helping patients manage their chronic conditions and appropriately navigate the health system. The program, which began in October 2022, is focused on steering patients away from calling 911 or presenting to EDs with nonurgent care needs.
The pilot grew out of conversations between MHN and Katie Tataris, MD, MPH, an emergency physician and the University of Chicago’s EMS medical director. “We felt like we were missing ... a connection to what happens to patients when they are discharged from the hospital or when they’re seeking primary care or chronic care management in the ED,” says Ashley Kloos, MPH, director of enterprise care innovation and quality at MHN.
Paramedics are trained to build relationships with their communities by providing coaching and health management skills. MHN works with medical homes and the community paramedic program. Perhaps these two groups could join forces to target a select group of chronically ill patients who visit EDs often, according to Stephen Stabile, MD, medical director of MHN and MHN’s Accountable Care Organization.
In the pilot, the participants are all Medicaid patients who live in specific ZIP codes on the south side of Chicago, all of whom are served by a specific EMS team. The patients also must be impaneled to one of the Federally Qualified Health Centers with which MHN is partnering.
Kloos says EMS and MHN are looking for specific conditions: hypertension, diabetes, heart failure, and asthma. Along with one or more of these conditions, some patients also are managing depression or anxiety. Care managers, transitions-of-care nurses, or other MHN providers may see these patients accessing hospital care for their chronic conditions.
Once someone determines a patient is eligible to participate, staff prepare a referral form, which includes some basic patient information. Then, staff send that form to the Chicago Fire Department community paramedic team. “They will reach out to the patient [by phone], introduce themselves, and talk about their connection with the patient’s care manager or primary care provider, and explain what services they will provide,” Kloos explains. “Then, if the patient is interested in participating, the paramedics will set up a time for a home visit.”
The paramedics carry out the home visits in groups of two. “While they provide tons of education and coaching, the most important part of this process is building a rapport with the patients,” Kloos says. “When [EMS] go out into the community and they go into patient homes, they are really able to talk with them and build that relationship from the time they walk through the front door.”
Over the course of this visit, paramedics can assess the home for safety, review all the patient’s medications, and check to see if the patient needs any refills or requires delivery. EMS also completes any disease-specific assessments and provides coaching on how to better manage their chronic conditions. “Patients really are able to become true advocates for their care, and to seek care at the right place at the right time, and feel confident in doing so,” Kloos stresses.
Stabile says these paramedics are “the eyes and the ears of the care team” who can serve as “the conduit from the patient to the care team.”
“They’re experts in quickly assessing home situations,” Stabile adds. “In this program, they have more time than they are probably used to because they have an initial home visit and several follow-up visits.”
Stabile notes the chief points of contact for the paramedics are MHN care coordinators, who interface with the patients’ primary care providers and other members of the care team. Stabile believes what separates the MHN approach from other community paramedicine programs is the fact the paramedics are tied directly back to each patient’s specific medical home, and they are essentially part of the broader medical care team.
In total, participating patients will be visited in their homes four times — although the time it takes to complete the visits will vary with the needs and wishes of the patients.
“At their fourth visit, we consider it the graduation point of the program, and they get a certificate,” Kloos says.
While the MHN program is young, the early results show promise. As of August 2023, MHN reports the most common situations addressed by the paramedics included: medication reviews (100% of patients), transportation service referrals (58% of patients), medication delivery services (47% of patients), scheduling follow-up appointments (54 appointments scheduled), and identifying home equipment needs (36 needs identified).
Further, the paramedics have made 78 house calls, and MHN have charted a 52% decrease in hospitalization rates and an 87% decrease ED use rates among the participating patients. A full data review is expected to happen this fall, when leaders will consider the potential for program continuation and expansion.
Chicago-based Medical Home Network is partnering with community paramedics at the Chicago Fire Department on a program aimed at helping patients manage their chronic conditions and appropriately navigate the health system. The program is focused on steering patients away from calling 911 or presenting to EDs with nonurgent care needs.
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