North Memorial Community Paramedic Program One year into it The first year • • • • • 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) • • • • 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 • • • • 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 • • • • • • • 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 • • • • 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 • • • • • • 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.