Chronic Care Reinvented: Leveraging Paramedicine To Reduce Readmissions

Sometimes real change in health care comes not from innovating or redesigning existing models of care, but from considering a problem from a completely new point of view. One solution that fits this description and is currently gaining traction around the nation is Community Paramedicine, a care delivery model that leverages the untapped resource of paramedics to address non-emergent health issues before patients are transported to the hospital.

Practically every emergency medical system in the US can attest that many of the “emergency” calls are not necessarily for emergent issues that require hospitalization or even transport. Many of these calls are from patients who require EMS response, but not a hospital visit — and sometimes these patients call frequently. At New Hanover Regional Medical Center, a tertiary care teaching hospital and regional referral center based in southeastern North Carolina, we refer to these patients as “familiar faces.” During 2013, 29 percent of all 911 requests to NHRMC were for non-emergent situations, and more than 700 of these came from the same 10 “familiar faces.”

NHRMC is a rare hospital that operates its home county’s EMS system, which provides us a distinct advantage in addressing this problem. We already had access to paramedics, who are educated in advanced emergency care delivery, and could deploy them proactively on tasks as basic as routine follow-up care, reminding patients to take medications, or arranging a ride to a doctor’s appointment. Paramedics can assess the patient’s condition and care requirements before making an informed decision to treat onsite or seek additional medical assistance. By reaching patients in their homes, paramedics have the opportunity to solve basic medical and social needs and reduce stress on the patient, which helps improve satisfaction.

Beyond the patient level and from the perspective of the medical center, we saw the opportunity to reduce the burden on overcrowded EDs and prevent avoidable hospital admissions. To test this new way of thinking, NHRMC launched a 6-month pilot program to measure Community Paramedics’ ability to successfully address patients’ non-emergent needs at home, a project generously funded by a grant from The Duke Endowment.

The pilot measured the impact of Community Paramedicine on two patients: one “familiar face” and one congestive heart failure patient who regularly made 911 calls. When these patients had non-emergent needs, they were encouraged to call their assigned Community Paramedic instead of 911 to address their needs at home.

After only six months of the pilot program, we saw some impressive numbers. The familiar face’s visits dropped from 13 ED visits during the year prior to just one, while the CHF patient’s hospital visits were reduced to one (for anemia), compared to five over a 5-week period prior to the start of the pilot.

Seeing the program’s success, NHRMC leadership agreed to expand its support, and the majority of these additional efforts showed comparable results. In the last six months of 2014, the 30-day readmission rate of congestive heart failure patients in the program was just 9.3 percent, significantly below the national average of 20 to 25 percent.

As a result of its early success, NHRMC secured another grant from The Duke Endowment to focus on further reducing 30-day readmissions for CHF patients, adding two more community paramedics (bringing the total to five), but this time in combination with a dedicated pharmacist and telephonic case managers who followed up with patients at home.

In the first quarter of 2015, we’ve seen more exciting results. The readmission rate of all patients in the Community Paramedicine program is 9.1 percent, compared to the national average 30-day readmission rate of 15.2 to 25 percent. The EMS team is now trying to expand the Community Paramedicine program’s success while improving patient outcomes and delivering a positive patient experience.

Several factors were critical to the success of our pilot program. One was 300 hours of education, both in basic care and specialized areas, which included 200 hours of clinical application. Each Community Paramedic was educated in advanced disease management as well as social and behavioral health, which gave them the necessary skills to develop longer term personalized relationships with their patients and identify risk factors in their lifestyles and homes.

Another key factor to success was working with a partner like Philips, which believes strongly in the program, and partnered with NHRMC to spread knowledge and raise awareness around the impact of the benefits of Community Paramedicine.

More than 200 Community Paramedicine programs exist in several EMS agencies around the country today, according to the National Association of EMTs. The success of NHRMC’s program shows that by capitalizing on existing resources within the system and thinking about them in a new way, then finding the right mix of education and external partners, health systems can achieve higher impact with a relatively low investment.