Two programs launching to reduce hospital readmissions, ease ER overcrowding
The UCLA Center for Prehospital Care and collaborators from the Los Angeles County Emergency Medical Services (EMS) agency and the Glendale and Santa Monica fire departments are launching two pilot programs designed to reduce hospital readmissions, address overcrowding in emergency rooms, lower healthcare costs and boost patient satisfaction and quality of life.
The Community Paramedic Pilot Programs expand the current roles of Glendale and Santa Monica paramedics, allowing them to more closely interact with members of their communities.
The programs are the result of a report by the Institute of Medicine a decade ago that recommended finding alternative ways to deliver healthcare using emergency medical services agencies. That report then resulted in the federal government instructing communities to think about the future of EMS agencies and how they could better provide and expand their services.
"EMS traditionally responds to 9-1-1 calls only. They find a patient with a problem and transport them to an emergency department. The thought was maybe there were other patient care delivery options these very well trained professionals could perform," said Dr. Baxter Larmon, an adjunct professor of emergency medicine, director of California State Community Paramedic CORE Education and co-principal investigator of the UCLA pilot projects.
Because state law dictates what duties EMS can perform, it was determined that programs should go through the state Office of Statewide Health Planning and Development, which can run pilot projects outside of state laws and regulations. A request for pilot projects was sent throughout the state and 13 projects, including the two run by UCLA, were approved. UCLA's are the only projects being tested in Los Angeles County.
To be launched Sept. 1 in Santa Monica and within several weeks in Glendale is the Alternate Transport Program which, with patient approval, transports patients with less serious medical complaints to one of several approved urgent care centers for treatment instead of to an emergency room. Wait times are much shorter at urgent care centers and ambulances and their crews will be back in service much more quickly. Dignity Health Glendale Memorial Hospital and Glendale Adventist Medical Center are participating in this program, as well as UCLA Medical Center Santa Monica.
Larmon said that many calls to 9-1-1 don't rise to the level requiring emergency department resources, and often can easily be handled at urgent care centers.
The Glendale and Santa Monica paramedics in the program received additional training through UCLA to help them determine which patients would be appropriate for consideration for transport to an approved urgent care center, and which had conditions that would be better evaluated and treated in a hospital emergency department.
"Our primary goal is to reduce overburdened emergency departments receiving patients with minor illnesses or injuries," Larmon said. "Research has shown that wait times in busy emergency rooms can be up to six hours. In our program, we hope patients will be seen considerably quicker than that, which will be better for emergency rooms and patients."
The second pilot program will be done in Glendale with Glendale Adventist Medical Center and the Glendale Fire Department. Also launching Sept. 1, it focuses on patients with congestive heart failure (CHF) who have recently been released from the hospital. Patients would receive a home visit from paramedics specially trained to assess and evaluate their symptoms, ensure they are taking their medications correctly, eating a heart healthy diet and that their home environment is conducive to them remaining healthy enough to continue to stay at home.
Most hospital readmissions for CHF patients generally happen in the first 48 to 72 hours, so the home visits will occur in this critical window, said Dr. Steven Rottman, an adjunct professor of emergency medicine and principal investigator for the pilot programs.
Rottman said the programs are modeled on those set up in more rural areas, where patients might not live near a major medical facility. Those programs, he said, have proved successful.
About 64 percent of hospital readmissions for CHF patients occur within seven days, with half of those within the firsts three days, he said.
"There's obviously a missing link in the chain of care and that's what we're trying to crack with this program," Rottman said.
A patient readmission fills a hospital bed that is already at a premium. Additionally, Medicare is not reimbursing hospitals for these patients and, in fact, is fining medical facilities for readmitting patients with specific conditions like CHF within 30 days after being discharged.
"Going back to the hospital is a disruptive experience for the patient and may not improve their quality of life," Rottman said. "Anything that we can do to cut costs, save hospital beds and give patients a good quality of life would be a vast improvement."
Paramedics are experienced in assessing and stabilizing ill patients outside of a hospital setting, and during a home visit can test such vitals as blood oxygenation, perform an EKG and get guidance from a physician consultant on whether an immediate appointment with a primary care physician is required or whether hospitalization is necessary. The paramedics will serve as gap fillers between hospital discharge and the patients' first follow up visit with their physicians.
If patients can make it through that critical first week, Rottman said, they may be able to avoid hospital readmission.
Cathy Chidester, as director for Los Angeles County Emergency Medical Services, submitted the pilot programs to the state for review and approval. She believes the programs will benefit the county's EMS system as a whole, keeping ambulances and paramedics free to respond to legitimate 9-1-1 calls. She said off-load times, the period in which paramedics must wait at the hospital to hand the patient over, can range from 20 minutes to an hour, time when they could be attending to other patients.
"We're excited about starting the pilot project, and we're really happy to work with UCLA on this," she said. "If we're successful, both of these programs could be utilized all over the state."
Santa Monica Fire Chief Dennis Downs said his team looks forward to taking part in the Alternate Transportation Program.
"The reality is we all benefit by getting a patient to the right place the first time," Downs said. "Taking a patient that qualifies to a lesser critical facility makes all the sense in the world."
Glendale Fire Chief Gregory Fish agrees. He said average wait times at hospitals for Glendale paramedics averages 23 minutes, a fairly low number that he attributes to the city three high quality hospitals.
"But if we could get that number down, that would be fantastic," Fish said, adding that the partnership between all the parties has been gratifying and his department will continue to experiment with other healthcare delivery modalities.
Dr. Arby Nahapetian, regional chief medical officer for Southern California Region Adventist Health, said his team is "very excited about the potential to help contribute to efforts that increase the health of the populations we serve by reducing both readmissions and opening our Adventist Health urgent care network to lower-acuity ambulance traffic."
"These types of partnerships hold great promise for our community," Nahapetian said. "Heart failure is a chronic disease and this program will provide enhanced services at discharge in order to better coordinate a smooth transition for our patients. The first few days following discharge for heart failure patients are a critical time."
Patients will need to sign consent forms to enroll in either program, both of which are expected to take about a year to complete. The data will be analyzed to determine if hospital readmissions were reduced and emergency rooms were less crowded.