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The Impact of EMTs on the Post-Discharge Transition of Care
From the July issue of Integrated Healthcare Delivery.
EMS is most commonly appreciated for its vital role in 9-1-1 emergency medical response. However, it’s often utilized as a source of medical transportation for nonemergency patients who are unable to be transported by traditional means. This includes transporting vulnerable patients who have been discharged from a hospital or emergency department. A significant number of these patients transition directly from the hospital’s acute-care environment to the patient’s own home environment.
It is well documented that the transition from the hospital to the home is susceptible to lapses in quality and a loss of key information regarding a patient’s care.1 Following an acute hospitalization, as many as 76% of elderly patients are confused about their follow-up care plan.2 Forty percent of patients over age 60 will experience a fall in the next six months.3
For too long, our fee-for-service healthcare system has rewarded an arrangement that paradoxically benefited organizations when patients experienced a poor-quality healthcare transition, often resulting in a hospital readmission. Meanwhile, the EMS reimbursement model emphasizes transportation over the provision of care.4 In addition, varying degrees of regulatory issues and organizational cultural issues have allowed an entire workforce to remain underutilized and disassociated from the rest of the healthcare system. As the population ages, there will be an increasing demand for the healthcare system to transform the current model of emergency care, including healthcare provided by EMS.5
Thankfully recent trends in healthcare policy, accelerated by the Affordable Care Act, have begun realigning incentives toward a coordinated experience that crosses over individual medical disciplines, workforces and institutions with the goal of improving patient outcomes. In light of these changes, EMS agencies and their providers are exploring new opportunities to achieve the long-held vision of a clinically integrated mobile healthcare service with reimbursement linked to value.6
The convergence of these two macro trends has enabled a unique pilot project that seeks to demonstrate the value EMS can provide in the transition of care.
Transport PLUS
The Transport PLUS project is a collaborative effort between Mount Sinai Medical Center in New York City and TransCare, Inc. a private ambulance service provider. It’s funded through a CMMI Health Care Innovation Award for the hospital’s GEDI WISE (Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, & Structural Enhancements) program. The project aims to determine the feasibility, acceptability and effectiveness of using EMS providers to perform a discharge instruction comprehension assessment and home fall hazard assessment for patients over age 65 and their families or caregivers; this is done during routine transports to the home following discharge from an ED or inpatient unit.
Unlike most projects under the banner of “community paramedicine” or “mobile integrated healthcare,” this pilot utilizes the skills of an EMT-Basic, rather than a paramedic. While the majority of other programs involve removing providers from traditional EMS roles and placing them in a dedicated nontransport position, Transport PLUS emphasizes a “systems approach” to mobile integrated healthcare where providers of all types, and at all times, function in an integrated healthcare role. By expanding the EMT’s role in healthcare without broadening the scope of practice, we hope to identify EMTs as a valuable, underutilized and often overlooked member of the continuum of high-quality healthcare delivery.
The EMT conducts a structured discharge comprehension assessment with the patient or caregiver sometime between their initial visit at the hospital and the patient’s setting in back home. The EMT must use his or her judgment to determine if the patient or caregiver is aware of the six basic pieces of information generally included in discharge instructions. These have been adapted from the four pillars of transitions of care and include medication self-management, follow-up instructions and knowledge of “red flag” symptoms.7
The EMT helps by reinforcing the written discharge instructions. If an element is not addressed in those instructions, the EMT can facilitate getting answers from the hospital or ED.
They also conduct a home fall hazard assessment. This includes a brief scan of the home or apartment for easily recognized fall hazards. An extensive literature search, including publications from the fields of nursing and physical therapy, generated a list of 90 potential fall hazards in the home. A final list of 11 was compiled by prioritizing the most prevalent hazards and identifying those easily and reliably assessed and modified by the provider, patient and/or caregiver. Those common hazards include throw rugs, wires/cords, the absence of grab bars and obstructed walkways.
We estimate these two interventions will add between 5–15 minutes to the total task time associated with these patient transports. Given existing unit utilization and capacity, this is expected to have a negligible effect on overall operations for the EMS agency.
Implementation
We developed a two-hour training module for the EMTs, which includes approximately one hour of didactics and brief simulations of the two interventions included in this program. For the purposes of the demonstration project, a pre- and post-test were also administered.
It is worth noting that the EMTs were frequently interviewed for feedback during the initial training sessions and contributed significantly to both the design of the checklists as well as the training itself. The initial training sessions were performed in person, but an online training module has been recently developed that will allow us to complete the training of 100 providers in the near future. Those already trained have begun performing the interventions.
The implementation process has resulted in numerous interesting anecdotes and many small discoveries. Two worth sharing have to do with what healthcare transformation looks like on the ground level.
First, each encounter in which the EMT attempts to communicate with the hospital to address an issue with discharge instructions has the potential to be transformative. Since this is a new and more healthcare-oriented role for the EMT and because post-discharge care has not historically been a major focus, hospital-based healthcare workers (physicians, nurses, social workers) have highly variable responses and sometimes require substantial orientation to the program.
Second, while most discharge instruction education is provided to a patient or family member, the person present when the EMT transports a patient home is often a home health aide (HHA) who isn’t updated regarding the patient’s condition or new treatment instructions. Ensuring the HHA understands the discharge instructions may be pivotal to the prevention of return ED visits and readmissions.
Furthermore, it is a truly transformative moment for healthcare when an EMT and an HHA, two often overlooked participants in a patient’s care, are engaged in a meaningful discussion about how to care for a patient post-hospitalization.
Evaluation and Dissemination
To evaluate the efficacy of the program, the project coordinators are performing two-week follow-up phone calls. We assess patient and provider acceptance, the number and types of fall hazards discovered, the rate at which fall hazards are being removed, and the rates and types of gaps in understanding of discharge instructions.
A select number of patients also receive a secondary home visit by a community health worker to validate the EMT assessments and review the accuracy of the data received by the follow-up calls. We hope to ultimately compare the rates of readmissions and return ED visits among patients who received the intervention to those who did not.
We look forward to sharing the results of the Transport PLUS demonstration project in 2015. We believe our contributions will add value to the evolving landscape of mobile healthcare. Indeed, we believe this program is highly generalizable, inexpensive and relatively easy to implement. It can be incorporated into an agency’s routine service and perhaps provide an initial foothold for community paramedicine. If successful, it would demonstrate that potentially every aspect of the EMS system, and all levels of providers, could be part of the transformation of EMS into a mobile integrated healthcare delivery system.
References
1. Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med, 2004 Oct 5; 141(7): 533–6.
2. Advisory Board Company. Succeeding Under Bundled Payments. Data analyzed from Get With the Guidelines—Heart Failure registry, 2010.
3. Hill AM, Hoffmann T, McPhail S, et al. Evaluation of the sustained effect of inpatient falls prevention education and predictors of falls after hospital discharge--follow-up to a randomized controlled trial. J Gerontol A Biol Sci Med Sci, 2011 Sep; 66(9): 1,001–12.
4. Munjal K, Carr B. Realigning reimbursement policy and financial incentives to support patient-centered out-of-hospital care. JAMA, 2013 Feb 20; 309(7): 667–8.
5. Hwang U, Shah MN, Han JH, Carpenter CR, Siu AL, Adams JG. Transforming emergency care for older adults. Health Aff (Millwood), 2013 Dec; 32(12): 2,116–21.
6. Delbridge TR, Bailey B, Chew JL Jr., et al. EMS Agenda for the Future: where we are…where we want to be. Prehosp Emerg Care, 1998 Jan–Mar; 2(1): 1–12.
7. Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc, 2004 Nov; 52(11): 1,817–25.
Thanks to the following people for their contributions to this manuscript: Nadir Tan, BA, Glenn Youngblood, BA, EMT-P, Lynne Richardson, MD, Corita Grudzen, MD, MS, Kevin Chason, DO, & Ula Hwang, MD.
Disclaimer: This article’s contents are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.
Kevin G. Munjal, MD, MPH, is a board-certified emergency medicine physician who completed an EMS fellowship with the New York City Fire Department (FDNY). He also has a Masters in Public Health from the Columbia-Mailman School of Public Health. He is the founder and chair of the NY Mobile Integrated Healthcare Association (NYMIHA), an organization seeking to empower EMS providers to play a larger, more integrated role within our healthcare system by promoting new models of mobile healthcare care better aligned with new accountable care organizations. He is the associate medical director of Prehospital Care and co-chair of the Mount Sinai Health System EMS Committee in New York. He is an accomplished and prolific academic researcher funded through both the National Institute of Health and the Center for Medicare and Medicaid Innovation for his work in community paramedicine. His recent JAMA paper advocating for realignment of EMS Payment Policy has received significant notoriety.
Hugh Chapin, MD, EMT, recently completed his medical degree from St. George’s University and is currently the project manager for Transport PLUS based out of the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai. He also earned a Masters of Science in Biomedicine at the Johannes Gutenberg University Medical School in Mainz, Germany. He is a fellow for the NY Mobile Integrated Healthcare Association and is actively involved with the growing field of community paramedicine. He remains an active EMT in New York City.
