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As healthcare organizations increasingly look to move care from the hospital to the home, some are exploring community paramedicine, which integrates emergency medical service providers into the care team. That is why Geisinger Health System, a large integrated delivery network that is based in Danville, Pa., and includes 12 hospital campuses, launched a mobile health paramedic service in 2014 for its Geisinger Health Plan members and established Medicare patients. The program, piloted at Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pa., includes three mobile health paramedics employed by Geisinger.
“When we developed this program, we wanted a nimble and flexible service that could render specific clinical interventions and communicate patient care needs back to the care team in an integrated way,” says David Schoenwetter, DO, FACEP, medical director, emergency medical services.
Home care and visiting nurse services face limitations, particularly in response time, flexibility, and scheduling, Schoenwetter says. Take a patient with acute exacerbation of chronic respiratory issues, for example. Although a visiting nurse can provide routine assessment as part of a physician care plan, a mobile health paramedic can respond quickly if the condition worsens, such as if the patient develops a fever or increased respiratory distress. “This closes the gap in care that exists when patients are deciding between waiting for the visiting nurse to come or going to the emergency room,” Schoenwetter says. “The mobile health paramedic can provide an acute response to the patient and provide information back to the care team.” Sometimes the paramedics will need to bring the patient to the hospital, but other times they resolve the patient’s issue in the home.
“While the industry is looking at how to provide the right care in the right place, we wanted to make sure that we were also addressing the right time,” says Kathleen Sharp, MBOE, LBB, senior performance innovation consultant, population health initiatives. Mobile health paramedic programs not only help prevent costly admissions but “also help organizations take a patient-centered approach,” Sharp says.
Geisinger’s Mobile Health Paramedic Program implementation team (from left): Martin Mahon, EMT-P, FPC, manager; Kathleen Sharp, MBOE, LBB, senior performance innovation consultant, population health initiatives; Michael Boyer, EMT-P, paramedic; Robin Fike, NREMT-P, paramedic; Roni Koval, EMT-P, paramedic; Jack Lasky, EMT-P, emergency medical services coordinator; and David Schoenwetter, DO, FACEP, medical director. (Photo: Geisinger Health System)
Sharp says the most challenging aspect of getting the program off the ground was demonstrating its potential financial value. Over the years, emergency medical services have evolved as a transport benefit, which limits the reimbursement potential for such programs—at least for now, Sharp says.
“The program is designed to give the right care to the patients at the right time, but it is not something that we can currently charge for,” she says. “As we were approaching administrators and asking for support for the program, demonstrating the financial value was a key challenge, although the value from a quality and service perspective was easy to demonstrate. For this reason, being able to collect the right data has been critical.”
Since 2014, the program has recorded nearly 4,700 patient encounters, which include home visits, phone calls, and in-person support given by paramedics in medical homes and other clinics. Today, the program manages 760 unique patients and averages 26 home visits per month. At press time, the program had prevented more than 100 hospitalizations through the ED alone.
Some of the biggest successes have come in managing heart failure patients. During the pilot, which followed 202 heart failure patients, 30-day readmissions fell by 15 percent at 90 days post-intervention, compared with at 90 days pre-intervention. Total facility encounters (admissions and ED visits) were cut in half. That patients who were admitted had an increased length of stay actually was considered “a second win because these were the people who truly needed to be admitted,” Schoenwetter says.
The team also saved nearly 600 inpatient bed days, the equivalent of adding two telemetry beds in the hospital for a year, he adds. “Those numbers were very compelling for our administration,” he says. “To essentially make capacity in the hospital by keeping people out was very motivating for the leadership.” Schoenwetter is hesitant to provide a hard cost-savings number but says the program has saved millions in charges and produced significant savings in avoidable costs.
Geisinger’s Mobile Health Paramedic Service Improves Care for Heart Failure Patients
Geisinger also has achieved a 100 percent five-star patient satisfaction rate with the program, based on a 78 percent response rate. The satisfaction rating survey has been independently verified, Sharp says.
Schoenwetter stresses that Geisinger’s mobile health paramedics do not have an expanded scope of practice but instead provide focused clinical services within their scope of practice. For example, they obtain histories, perform physical examinations, and take electrocardiograms and pulse oximeter readings. They also draw laboratory studies and administer intravenous diuretics to manage heart failure patients.
Although their scope of practice has not changed, the mobile health paramedics have an expanded role that requires more communication with the care team, which includes primary care physicians (PCPs), cardiologists and other specialists, case managers, and other professionals. “Our paramedics are not just doing simple checks on well patients,” Schoenwetter says. “Our program manages medically complex patients who require an integrated care approach.”
Geisinger also uses its mobile health paramedics to follow up on patients discharged from the emergency department (ED) through its Discharge PLUS program. “We evaluate the patient’s home for safety, review discharge instructions and medications with the patient, and make sure they are well-connected with their specialists and PCPs,” Sharp says.
Any Geisinger physician can initiate an order for a mobile health paramedic to see a patient. However, emergency physicians, cardiologists, and PCPs in medical homes initiate most referrals. “We are not like a home health agency in which the patient can call and ask for the service,” Schoenwetter says. “We require a referral by a Geisinger physician—not for payment but for clinical integration.”
For nearly a quarter of patients in the program, the first visit by mobile health paramedics was initiated after an ED visit, Schoenwetter says. Forty-three percent of contacts made by the mobile health paramedics are related to heart failure.
Before the program went live, the mobile health paramedics received additional training from Geisinger’s system chief of advanced cardiac disease to make sure they had adequate pharmacology knowledge and assessment tools to assist the care team in managing these patients. Geisinger also provided training on integrating with case management to make sure the mobile health paramedics understood how to work within the medical home model.
“The mobile health paramedics needed to understand the importance of building the relationships with case managers, PCPs, and cardiologists, as well as their client base of patients,” Sharp says. “It’s a different role for paramedics. In addition to the rapport mobile health paramedics build with patients and their family members in the home, they are using those same skills with the different medical practices and services that are referral bases for them.”
Training was provided to make sure the paramedics could use the mobile and audiovisual technology that allows physicians to interact with patients during home visits by the mobile health team, when needed.
Schoenwetter and Sharp offer the following advice to organizations looking to implement community paramedicine in their market.
Have strong executive sponsorship. “It is important that your program be in alignment with the broader objectives of your organization,” Schoenwetter says. “We have an advantage because we are an integrated delivery network with our own health plan.”
Make sure your IT is integrated enough to support mobile health. “Many health systems do not think about making their EHRs available to paramedics, but you have to with a mobile health program like this,” Sharp says. “We had to make sure we had all of the clinical information flowing to and from the field.”
Collect data, but keep it simple at the start. Geisinger paramedics needed to learn how to collect data to gauge the performance of the program. “We started with a simple sheet on which they logged four elements,” Sharp says. “Now we have six tabs of a spreadsheet with 26 metrics that they log.” Beyond avoided readmissions and ED visits, the metrics include volumes of services segmented by specific populations. The paramedics also track their time in the home and on the phone with patients to gauge efficiency.
Have paramedics attend medical home meetings to improve relationships with primary care providers. “This gives paramedics an opportunity to hear from a large group of stakeholders about what they need from the program,” Sharp says.
Understand the need in your community. “Paramedics by their nature and training are flexible and can adapt to new clinical situations, given the appropriate tools,” Schoenwetter says. “You need to assess your community to determine where your health needs are at and if this type of service can add value.”
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.
Interviewed for this article:
David Schoenwetter, DO, FACEP, medical director, emergency medical services, Geisinger Health System, Danville, Pa.
Kathleen Sharp, MBOE, LBB, senior performance innovation consultant, population health initiatives, Geisinger Health System.
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