North Memorial Community
Paramedic Program
One year into it
The first year
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Over 1,500 patient visits
Primary Care focus
12 hour shifts 07-1900 (exception of Monday 8hr)
Referrals from ED/PCP/CC/HH
Connected with North Memorials Health Care Home team
• Increased continuity of care
• Active ‘team’ communication
• ‘Hub’ huddles promotes active goal setting and completion
• Encourages patient empowerment
• Established plans/proforma to expand hours
• Charting: from paper to electronic (EPIC)
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Billing prepared and ready to launch
Avoided service duplication successfully; receiving referral from HH
Established relationships in the clinic(s)
Created ‘hubs’ :promotes continuative care model
• Northwest
• South
• East
Getting to know our providers
pt visits
212
142
104
73
11
29
47
29
50
155
176
191
184
Patient Populations
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Polypharmacy
High ED utilization
• Not quite homebound: ineligible
for HH services
Anti-coagulation patients
• PCP feels it would help pt to have
Ages ranging from 7-98 (mean:
75.68)
• Projected to decrease with shift to
• HCH patients needing services
• Continued wound care needed
MA population
additional resources
Interoperability
Who are we connecting with
How we address communication
• Daily huddles with care coordinators
• Daily communication with scheduler
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Monthly meetings as a group
Regular HCDS communication (Medicaid population)
Planning for shared savings model (Medicare population)
In-basket Epic messaging: real time with provider for follow up/guidance
Lab contact for analysis and direction
CC’ing all charts to care coordinator and PCP
Closed loop communication with patient and family
Communication improvement process
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Increase CP program hours to offer patient more of a safety net
Participate in ACO and offer pt more in home services
Link additional community services into pt goal setting process
Meta-analysis revealed 12-34% of discharge summaries reach PCP by pt’s
first f/u appt (Kripalani, 2007)
• CP follow up upon D/C can increase information relay to PCP
• D/C lab review and med compliance offers decrease risk of re-admin
Goal setting process: DM example
• PCP/CC: Cp referral
• Referral to Diabetic educator
• Goals set shared with CP and brought
into home
• Referral to Dietitian
• Cp assists pt with locating resources:
especially in respect to food deserts
• A1C goals made by CP/PT
• Daily log book offered and checked
weekly
• Smoking cessation programs
offered
• Medication compliance/monitoring
• Assistive devices created by CP
Patient story
• Each patients needs are different
• CP referred to 63 yo female with hx of MR to assist with novolog/levemir
adm. Pt has special needs son and tends to neglect herself. CP assured PCA
was able to help with Rx’s in am and pm, CP then set up husbands cell
phone to vibrate and shout out (with cp's voice) everyday at noon, "blank,
Test your glucose and reference the placard for your dosing!". Seven day
average continues to drop and pt is very thankful.
Patient Story
• http://prezi.com/u3qxhrbfn4i7/?utm_campaign=share&utm_medium=cop
y
Shared Savings/VBP
• Iron Triangle/Triple aim future at focus of CP program
• Work with organization to determine where we ‘fit’ in helping to increase
TPS scores
• Continued focus on patient populations misusing ED as primary provider
• Reduction in re-admission rates through discharge follow up
• Continue increasing lab compliance at clinic level
• D5/V4 emphasis
The future
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Define additional criteria for data collection
Communicate with all other organizations to assure we all move forward
Work with hospital to establish plan of action for increased MA populations
Increase CP hours to meet the demand
Focus scheduling process on patient (hub) proximity to increase efficiency
Continue to provide quality, affordable, and easy to access care to all patients
we encounter
Parting words
• There is no doubt that the community paramedic visits, always eagerly
anticipated, have produced a healthier and safer environment for my parents
in their home. The Cp’s regular, weekly visits also mean that my parents have
a dependable person to answer their questions and resolve issues quickly
before they grow into problems that result in EMT visits, transport to the
ER and hospital stays.