Bringing Care to the Public

ROCHESTER – Cindy King, who has chronic obstructive pulmonary disorder, feels a sense of security knowing that regular visits from Frisbie’s paramedics not only help her to manage her disease, but that they may reduce the need for her to be readmitted to the hospital.

King, a Rochester resident, is part of a new pilot program that helps monitor patients recently released from Frisbie Memorial Hospital, a move that helps not only the patients, but also reduces hospital readmission costs through preventable hospitalizations.

Frisbie’s Mobile Integrated Healthcare Program is designed to mitigate gaps in care — post hospital discharge — and reduce chronic disease-related health complications by bringing medical services to the homes of individuals who have primary diagnoses of chronic obstructive pulmonary disease and congestive heart failure. The model employs community paramedic providers to better promote continuity of care, standardize chronic disease management and improve overall health outcomes.

Gary Brock, director of EMS for Frisbie, said they had applied for a grant through the Institute for Health to begin the mobile program, and when they didn’t get the grant, the hospital administration decided to fund a pilot program. Brock said they began with COPD and CHF patients on a part-time basis. They hope to continue and expand the program to encompass additional medical conditions, possibly including substance abuse disorders in the future.

“Eventually, we would like to be able to offer the service to all who are considered high users of the hospital,” Brock said. “That means people who are frequently admitted or seen in the emergency room. It’s a win for the patient and for hospital costs. The administration saw the value in that we may reduce admissions through better overall management of population health, allowing the hospital to recoup the costs of readmissions. We are bridging the gap between the release of a patient from the hospital and their ongoing care. Sometimes people do not know how to get the equipment they may need and we will help. We can educate them about taking better care of themselves, and we can monitor their health.”

Specifically, Community Paramedic Providers will provide follow-up care for patients discharged 24-36 hours from hospital and at high risk for emergency department utilization and/or hospital readmissions.

The CPP will assess the patient’s home for safety issues, assess prescriptions and conduct medication reconciliation, provide education on medical condition(s) and resources available to patients, provide support for patients with medical conditions deemed at high risk for emergency department utilization and/or hospital admissions and integrate acute and primary care in homes by using interactive, mobile technology and electronic medical records to relate evaluations and assessments to a medical team.

Brock said they have had 19 inquiries about the service already and are actively seeing seven people. They make daily phone calls to the residents in addition to their scheduled visits.

King, 58, said she has become close with paramedic Valeri Previe, who visits her regularly and offers her that sense of security.

“I went into the hospital with bacterial pneumonia,” King said. “No one told me about cleaning out my nebulizer. Now Valeri teaches me how to take better care of myself, so things like that do not fall through the cracks. She’s like my bridge to better care.

“When we started the program, we weren’t sure how the residents would feel about us coming into their homes,” Previe said. “What we found is that they welcome us, because it helps them feel more secure, knowing someone is looking out for them. Our visits are not chaotic like most EMS visits to their home would be in an emergency. Its relaxed and Cindy likes when I come.”

Previe’s help for King began immediately. She assessed her medication and discovered a discrepancy that she corrected through King’s doctor.

“We found she had two medications with the same purpose, one she had been taking before her hospitalization and a second added after,” said Previe. “We also discovered her heart rate was high and recommended a heart monitor. The doctors listened to our concerns and hers, agreed and we made the adjustments.”

Brock said their purpose is not to compete with home care services. He said many of the people they see are not home bound, are not eligible for home care but can still benefit from someone checking in and keeping an eye out for them.

“We are the first in the state to offer this service through the hospital,” Brock said. “We started in October and are part time, but we hope to eventually be running seven days a week, full time. This actually offers a whole new career path for EMS.”

King is still employed and wants to continue working. She is not ready to retire but feels a sense of security knowing if she needs them, the paramedics will come to her place of employment, too. By monitoring her, the hope is that she does better at home, can return to work and the need for hospitalization is reduced.

“I used to panic, which of course made things worse for my breathing,” King said. “I was embarrassed about the number of times I went for help, so I went from hospital to hospital. Now, I know I can call Valeri. I feel calmer and don’t immediately think I am dying.”

“For most of the people we are seeing this way, the outcomes have been very positive,” Brock said. “We are exploring the idea of at home electronic monitoring, for things we can track by computer and add another level of oversight. That may reduce the need for us to visit as often.”

“She is a trouper,” said Previe, of King. “She wants to maintain her normal and we feel like we can help her to do that. We come and check her vitals to track her condition. We watch for red flags and can address them before they become serious enough to require hospitalization. For Cindy, her lungs are like a campfire with burning embers. One infection can be enough create a breeze and to fan the fire. We can see it right away, where she might not.”

Members of the mobile team keep detailed logs of the care they give, and share information with the person’s primary care physician. They are compiling data to show the value of the service at the same time.

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