Transcript Lauren Parker, Administrative Fellow

Population Health Initiatives:
Community Paramedicine
Program
Lauren Parker, Administrative Fellow
Phases for Objectives
Phase 1:
Focused on Full-Risk
CHF/Heart Failure
Patients within the CIN
Violet, Whitehall,
Truro Township Fire
Departments;
Metropolitan
Emergency
Communications
Center (MECC).
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Phase 2: Other
Attributed Members,
ACOs, MSSP, Other
Primary Diagnoses
Phase 3:
Underserved
Populations
CHF Pilot
• Patient Population
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5-6 Patients per Community Paramedic (Violet, Truro, Whitehall)
Primary Diagnosis: CHF/Heart Failure
Attributed within Population Health/CIN
Can be referred from CHF Clinic, Inpatient, or the participating Fire
Departments
– Residence within Violet, Whitehall and Truro Townships
• Services
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Initial 1-2 hour visit assessment
Additional 0.5-1 hour visits for monitoring and as needed
Time of dispatch to completion: 1.5 hours
Referrals to Home Care, Behavioral Health, Social Services, Follow-up
with PCP or CHF clinic etc., if needed
Training and Orientation
Rotation
Hours
Street Medicine – Homeless Coordinator (Ben Sears)
16
Mobile Coach Social Work/Case Management
8
Mobile Coach
16
Hospice
32
Hospital Based Social Work/Case Management
16
CHF Clinic
16
Shadow the PA
16
Patient Advocate
8
Home Health Nursing
16
Emergency Department with Physician
16
Primary Care Physician’s Office
8
Diabetes Clinic
8
Mental Health Center (NetCare (Franklin Cty)/Mound Builders(Licking Cty)/New Horizons (Fairfield Cty)
8
Odds & Ends
8
Total
192
Community Paramedic Mentorship
40
Grand Total
232
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Inventory of Services
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• Physical Assessment, vital signs,
•
biometrics
• Social assessment, quality of life
assessment, mental health
•
evaluation
• Environment check / home safety /
fall risk
•
• Respiratory assessment
•
• Point of care testing
• Referrals if needed to home care,
behavioral health, SNF, extended •
care, dietetics, etc.
•
• Health coaching
• Medication reconciliation
• Pain management
• Infusion needs
Communication with providers,
care managers, home care, social
workers, etc.
Scheduling appointments, setting
up with a primary care physician,
follow-up visit, etc.
Arranging transportation to
appointments
Patient education, reviewing postdischarge instructions
Advanced directives / goal setting
Such other services within the
scope of the Paramedic’s licensure
as requested by MCHS from time to
time
Toolbox of Essential Equipment for
November 1st Pilot
Stethoscope
Cell phone
Pulse Oximeter
Laptop
Point of Care Tool (K+ and effect of
diuretics)/iSTAT
Omega Car
Scale
A1C Monitor (1-2)
Thermometer
Glucometer
AED/Monitor
Blood Pressure Monitor
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Post Phase 1: CHF Pilot
• Metrics will be evaluated for pre and post
pilot
• Gaps will be addressed
• Eventually continue into the Phase 2 Action
plan covering additional attributed lives, hiring
and training additional Community
Paramedics, developing additional protocols
and broader more robust scope of practice
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Evidence-Based Metrics to Track
• No shows at CHF Clinic
• Frequent flyer list: Pre and Post
– Define frequent flyer list
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Reduction in ED Visits
Reduction in total cost of care (because of THIS program)
Reduction in Readmission (30 days)
Primary Care Physician utilization
Medication Inventory
Unplanned acute care use within 6 hours
Satisfaction with Community Paramedic
Behavioral Care Provider Use, Social Service Provider Use
Response time
Metrics will be shared for review
Documentation
• Referral “APP”
– Available for quick electronic referrals to Home Care,
Hospice and Care Choices
• Care Evolution: Social Assessment
– Used to track patient progress, update records with any
episodes or changes, identify gaps in care, behavioral
health evaluation, visible to physician offices, medication
compliance, helpful for metrics/tracking
• Fire Department EMR: Physical Assessment
– Vital signs, blood pressure, weight, medications, etc.
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Case Management Referral Process
Emergency Department
ER Case Manager
Triage
Patient must be:
1. In Population Health/Health Partners/CIN
2. Primary diagnosis of CHF
3. High-risk
4. Within the 43110,43068, 43147, 43213 zip codes
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Admitted
Observation
Treat and Release
Unit Case Managers
ER Case Manager
ER Case Manager
Community Paramedicine
Referral:
614-382-5913 or
[email protected]
Community Paramedicine
Referral:
614-382-5913 or
[email protected]
Community Paramedicine
Referral:
614-382-5913 or
[email protected]
Thank You! Questions…
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