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Utilizing Advanced Practice Paramedics to Reduce Hospital

ReadmissionsPresented by: Kevin Yarrow

Senior General ManagerVITAS Innovative Hospice Care of

Dallas

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CALL 911!

Patients and Families often panic & call 911 when:

There is a sudden change in conditionExacerbation of existing or new symptoms

Caregivers are unfamiliar with hospice services

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EMERGENCY DEPT.Patients experience: Long (and uncomfortable) wait times in the ED

Patient receives either palliative treatment they could have received at home, or unwanted aggressive treatment

Readmission to the hospital instead of their preferred setting for care (at home)

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ALTERNATIVE TO 911If the patient had called hospice first: Potential delays in on-call nurse arrivalEnduring uncomfortable symptoms for longer period of time

Additional delays after nurse arrives while waiting for medication, infusion supplies or other equipment to palliate symptoms

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Hospice/Hospital Impact

Lost revenue to hospice due to revocation for aggressive treatment

Emergency Department expenses paid by hospice if patent remains on service

Reputation affected for failure to manage patient ‘s care adequately at home

Potential penalties levied on hospitals for readmission within 30 days

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Paramedic SolutionParamedic can often arrive faster than a hospice nurse

Paramedics are trusted by the public to resolve emergencies quickly

Paramedics carry medications (including IV therapy) and equipment not available to responding hospice nurse

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Common Response Symptoms

Respiratory DistressUncontrolled PainUnresponsiveFallsChest PainBleeding

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Possible Interventions Assistance with prescribed meds in home Injury assessment and assist to bed Nebulizer treatment BiPap therapy Aerosolized pain medication administration Establishing an I.V. (hydration, meds) Wound Dressing High Flow Oxygen Transport to hospice General Inpatient bed

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Paramedic Partner Candidates

Local government run paramedic service (i.e. Fire & Rescue)

Private paramedic & ambulance company contracted to provide 911 dispatch/response (i.e. MedStar or AMR)

Private ambulance company with paramedics on staff

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Getting StartedIdentify the paramedic partner that best meets your need

Every jurisdiction (and county) may have their own rules governing paramedics

Customize the program to meet as many of your needs as possible given local regulations.

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Program OptionsIf the partner operates within the 911 call center, they may track your high risk for revocation patients in their system and notify you when your patient calls 911

Your partner may perform “pre-need” introduction visits to your patients

If your partner is outside the 911 system, you may still partner with EMS to defer to your paramedic partner in an emergency

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Pre-Implementation StepsAssist the paramedic service to develop a

palliative response protocol, or policy (to avoid transport to the nearest ED)

Develop a written agreement between your hospice and the paramedic company spelling out responsibilities, COP/HIPAA language and reimbursement for services.

Coordinate your Medical Director and the paramedic service Medical Director to establish order protocols

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Pre-Implementation StepsHave paramedic service extend physician

privileges to your hospice physiciansDevelop a formulary for medications stocked on the paramedic’s response vehicle.

Establish a step-by-step protocol for dispatch, sharing patient information, communication during the response and written report for patient’s hospice chart.

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Pre-Implementation StepsHospice provides training for paramedics

on caring for end of life patients, palliative symptom management and available options to ED transport (Continuous Care, General Inpatient, etc.)

Create a training program for hospice teams

Develop information collateral that describes the program for referral sources and patients/families

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COP ConsiderationsWritten Agreement with COP language (including hospice retains professional management of the patient’s care, background checks, etc.)

Paramedics (“Vendor”) educated by hospice

Hospice nurse is dispatched along with paramedic & updates Plan of Care

Hospice physician give orders to paramedic for on scene interventions

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Response Protocol Suggestions

Approval to dispatch required (assuming you are paying per response)?

Face Sheet, DNR, Med List (faxed or emailed to paramedic)

Provide name and cell of the hospice nurse enroute to paramedic

Provide MD on call name and number to obtain on scene orders

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Potential ChallengesFamily also calls 911 (prior coordination with Fire Department EMS supervisor may allow for transfer of care)

If paramedic arrives in an ambulance (vs. a non-transport vehicle) the family may push for transport

Most private paramedics will not respond with “lights & siren” so arrival may be longer than family expected

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After the CallObtain paramedic’s written report. Review in IDT and keep in patient chart

Communicate response activity to the team (if after hours) for follow-up

Communicate response outcome with patient’s Attending and/or other physicians

Track responses and share success rate.

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Questions?