A helping hand for elderly patients returning home

Aurora West Allis (WI) Medical Center knew that many of its most chronically ill Medicare patients struggled when they returned home following discharge from the hospital.

The medical center in suburban Milwaukee looked for a way to make sure these frail elderly patients got hands-on coaching and support within a day or two of going back home – the type of support that would lessen the chance of their returning to the hospital because of an unattended ailment.

It hit on an innovative solution: Pay community paramedics to visit newly discharged patients in their homes to make sure they understand their medications and instructions from physicians, and to assess their health and living environment.   

The program, called Transition in Care, is a partnership of the medical center and West Allis Fire Department. It aims to reduce the hospital’s 30-day Medicare readmission rates for certain high-risk patients, such as those admitted to the hospital with congestive heart failure, high blood pressure and diabetes.

The medical center passes on to paramedics the names of high-risk patients deemed to benefit from visits, based on the likelihood of readmission and historic indicators. After the visits, paramedics report key findings to Transition in Care’s registered nurses at the medical center for any needed follow-up care or services. All information is added to the patient’s electronic health record at the medical center. Each patient in the program receives at least one home visit.

“We are the eyes in the home,” says Captain David Bandomir, a registered nurse and the city fire department’s mobile integrated health care coordinator.

The paramedics were specially trained through community-based health care curriculum offered at the University of Wisconsin-Milwaukee College of Nursing. “There’s a laundry list of things we go through when we visit,” Bandomir says.

Things like making sure patients understand their discharge instructions, fill their prescriptions, have their follow-up appointment – and even understand what the follow-up appointment is. And do they know how to follow their low-sodium diet? Where do they grocery shop? Who is their insurance provider? Is the neighbor coming over to shovel the snow from their sidewalk? And, if requested, the paramedic might even put in a safety toilet seat or install hand rails in the shower.

The medical center launched the program in October 2015, after a three-month pilot project by the fire department showed a marked decline in non-vital 911 calls for visits to the hospital’s emergency department (ED).

“Not having eyes on them in the house was a huge gap for us,” says Patti Pagel, the medical center’s case management and transition care manager. “When the fire department told us what they were able to do through their pilot program and we saw the outcome, we thought this could be a community approach to taking care of frail, older adults.”

The medical center so far has enrolled 120 patients in Transition in Care. As of March, the program has contributed to a 20% decrease in 30-day readmissions to the ED and a 30% drop in overall hospitalization for the group.

Patient satisfaction with the program “is off the charts,” says Bandomir, who observes that the public generally views firefighters as one of the most admired professions. “People know us and trust us, and we leverage that trust” with Transition in Care, he says.

Patients also appreciate the hospital’s role in providing the service, says paramedic Brandon Foley.

“When we go into their home and say this is something the hospital is paying for because it is concerned about you, they just fall in love with the program,” he says. “No else provides free services like that.”

Pagel is confident that Transition in Care will be a successful long-term strategy for lowering health care costs while improving patients’ health. “We know this is going to show good outcomes and we want to move the program forward,” she says. “Even though it’s a fee-for-service model, it’s truly a community approach to providing care.”

But the partners acknowledge the conundrum of moving forward with a value-oriented strategy, like Transition in Care, in a fee-for-service payment world. Until bundle or value-based payment becomes more entrenched, they say it will be challenging for more health care organizations to embrace community paramedicine as a population health management tool. 

Still, Bandomir says care delivery models like Transition in Care can be replicated by other hospitals and health systems in other communities. “There’s nothing magical about a community paramedic,” he says. “But leadership from the top is critical.”

Pagel adds: “Everyone needs to be on the same page. This wasn’t just David and I saying this is a good idea – let’s do it. You need a lot of buy-in and support.”