What a Rural CP Program Is Revealing

For years Mike Schreiner had talked about using EMS staff to improve outreach to medically fragile and vulnerable people in his rural area of south-central Washington state. Now, with resources provided by a $1.5 million CMS Healthcare Innovation grant, his vision has come to life.

Schreiner is the manager of emergency medical services in the Prosser Public Hospital District. Its EMS jurisdiction covers hundreds of square miles of rural and remote territory in Benton and Yakima counties, as well as the cities of Prosser, Grandview, Mabton and Paterson. The area has high rates of obesity, high cholesterol, diabetes, heart attacks/coronary disease and angina/stroke. Schreiner believed Prosser paramedics had the time to take on a new challenge: using community paramedicine to improve preventive and follow-up care.

Sara Barron, assistant director of nursing and quality assurance at Prosser Memorial Hospital, said that to meet the conditions of the grant, PMH offered to identify at least 100 patients who had multiple hospital visits in the preceding 18 months. The goal was to reduce their hospital visits by at least 20% over the 18-month grant period. Achieving that would mean a $1.8 million reduction in healthcare costs from a $1.5 million investment. Exceeding it would save more.

According to Barron, PMH identified 119 patients who had collectively logged 795 hospital visits in the 18 months. These patients were categorized into one of three cohorts: 1) more than five visits for conditions other than pain relief; 2) open surgeries with risk of infection; and 3) patients with the potential to fall into cohort No. 1.

The 12 paramedics participating in the program received 96 hours of training, developed in conjunction with Heritage College’s nursing program, on home healthcare and support. When the medics receive a referral (discharging physicians refer at-risk patients to the community paramedic program’s RN case manager), they contact the patient at home to evaluate their access to prescribed post-hospitalization medications, compliance with medication instructions, integrity of post-abdominal surgery dressings, and to see if any problems or needs have come up. They also educate patients on resources that are available instead of using the hospital as a primary care provider.

Under Washington law, nonemergent home healthcare services like this fall outside a paramedic’s scope of practice. “We’re careful to talk to them about scope and remind them that when they are doing follow-up visits, they are working at a medically unskilled staff level,” Barron says. If CPs recognize a medical need, they must summon care if it is emergent or help the patient schedule an appointment with their doctor.

Initial Results

The program went live in January 2013. In its first 90 days, out of 132 referrals, CPs visited 92 patients. Of those, nearly one-third needed some type of intervention from the community paramedic. The most common were reminders to take medications and helping schedule follow-up doctor visits.

Barron says the discrepancy between referrals and visits was program leaders’ first real “a-ha!” moment. Some patients to whom they tried to refer community paramedics could not be found because they’d registered at the hospital with incorrect addresses or phone numbers. Others called back to cancel appointments.

In another unanticipated result, Barron says, “We expected to have the most effect on cohort No. 1, but where we saw the most dramatic decrease was in cohort No. 2 patients, because of better wound care.”

Schreiner is not surprised at the 30% intervention rate. “Despite their best efforts, the discharge environment at the hospital is not the most conducive learning environment,” he says, adding that as hard as hospital staff try, people are often more focused on getting home than on paying attention to a list of after-care instructions.

“We’re used to seeing people in their homes where they are more open and communicative,” Schreiner adds. “I think it makes for a better teaching environment when we go over their discharge instructions with them again.”

There was some initial confusion among the public about paramedics taking a proactive approach to their healthcare, Schreiner says, but the patients who participate are very appreciative. And Barron notes how well the paramedics have taken to their new roles. “Paramedics are telling me how satisfying this is,” she says. “They say, ‘It’s not blood and guts, but we’re making a difference. That’s why I got into paramedicine.’”

Physicians also have embraced the program enthusiastically and want to refer more patients than those in the initially identified groups. “We couldn’t be more pleased with their reaction,” Barron adds.

Ed Mund began his fire and EMS career in 1989. He serves with Riverside Fire Authority, an ALS-level fire department in Centralia, WA. His writing and photos have appeared in several industry publications. Contact him at mund.ed@comcast.net.

Sidebar: Community Medics vs. Navy Showers

An elderly man was being discharged from Prosser Memorial Hospital. Because of his age, near-total blindness and overall poor physical condition, staff asked him repeatedly if he had adequate help at home to continue his recovery. He assured everyone he had good neighbors waiting to help and that a daughter was coming in from out of town to take care of him.

Prosser community paramedics visited his home a few days later. They found him alone with no outside help from anyone. In talking with him, the medics learned he had told his daughter and neighbors he was fine and didn’t need their help, so no one had been by to see him.

He insisted he was doing OK, except for getting tired of taking “Navy showers.” “What do you mean?” the medic asked. The man related he was taking short, cold showers every day because there was no hot water. When the medics checked the hot water tank in the basement, they found it was not working because the basement was four feet deep in water.

They arranged to get his basement pumped, plumbing repaired and hot water turned back on.