RESPONSIVE. RELIABLE. RESPECTED.Case Study: Mobile Integrated

Healthcare Program Reduces 30-Day

Readmission Rate

MOBILE INTEGRATED HEALTHCARE PROGRAM REDUCES 30-DAY READMISSION RATESt. Louis, Missouri

THE CHALLENGE

Hospitals face growing scrutiny from payers and governmental

oversight bodies regarding hospital readmission rates for key

diagnoses. These diagnoses, including pneumonia, chronic

obstructive pulmonary disease (COPD), congestive heart failure

(CHF) and acute myocardial infarction (MI), are particularly

common in elderly patients.

Barnes-Jewish Hospital at Washington University Medical Center

in St. Louis, Missouri cited readmission rates (and the resulting

Centers for Medicare & Medicaid Services fines) as one of its

biggest concerns when administrators met with AMR subsidiary

Abbott EMS St. Louis in late 2012.

THE SOLUTION

David Tan, MD, medical director for Abbott EMS, knew exactly

how his organization could help. “Patients needed something that

traditional health care agencies, facilities or providers couldn’t

address, but we believed that our paramedics could,” he said. “We

knew that we could play a vital role in assisting local hospitals

with focused patient populations deemed at risk for hospital

readmission but who refuse home health or don’t qualify for

home health visits.”

The Abbott EMS Mobile Integrated Healthcare program

provides personalized and goal-directed care for patients who

are discharged from the hospital with pneumonia, COPD, CHF

or acute MI. The Abbott EMS team works with hospital case

management to identify patient needs for disease education,

outpatient clinic visits and transport planning. They also strive

to help patients better understand and manage their chronic

conditions to lessen their chances of acute exacerbations leading

to readmission within 30 days.

Care is provided by six Abbott EMS advanced practice

paramedics (APPs) with outstanding customer relations records,

as well as proven clinical and communication skills.

The six APPs participated in a 60-hour training program designed

by Dr. Tan, program medical director. Sixteen to 20 hours of

training occured in the classroom, while the remainder was spent

in an urgent care clinic with a physician.

“The clinical portion of the training helps the paramedics wrap

their arms around the fact that the goal is to help the patient

stay healthy in their own home rather than transport them to

the hospital,” said Dr. Tan. “They establish a relationship with the

patient, evaluate them for stability and go through the various

decision-making processes that a physician uses to decide

exactly how sick a patient is and what next steps to take.”

Dr. Tan works directly with a Barnes-Jewish Stay Healthy

Outpatient Program (SHOP) social worker who leads the patient

screening process and assists with operational quality assurance

and quality improvement. He also provides direct feedback to Dr.

Tan. Protocol checklists and patient feedback go directly to SHOP

and into the patient’s chart.

There are currently 25 patients either enrolled or who have

completed the 30-day program, with an ultimate goal of 100.

The APPs visit the patient’s home regularly. Depending on the

patient’s diagnosis, the APP can weigh them, provide breathing

treatments, run a 12 lead EKG and/or call their physician to

discuss the next treatment steps.

Day one through 14 include close follow-up and face-to-face

interaction between paramedic and patient, while days 15 through

30 consist mostly of phone calls or as-needed contact. “Patients

are at their highest readmission risk in the first 14 days after

they’re discharged, so if we can get them through that time

period, their chances of making it to day 30 are much higher,”

said Dr. Tan.

If the paramedic notices a symptom of concern, he calls the

Stay Healthy Clinic at Barnes-Jewish and speaks with a nurse

practitioner or physician to discuss a management strategy. “The

paramedic might say, ‘I’m with this patient, here’s what she was

diagnosed with, her discharge date, and how she’s feeling today.

Do you think this warrants a trip to the emergency department?

Or I can bring her to you in the clinic or should I give her a

treatment and check in on her tomorrow?’” said Dr. Tan. “It all

depends on what the paramedic sees or hears when he talks to

the patient.”

THE RESULTS

Though the new Mobile Integrated Healthcare program is still

gaining traction, early indicators point to great success. “Our

patient exit questionnaires are overwhelmingly positive, and the

patients are saying they’ve never received such attention before,”

said Dr. Tan.

The day one patient protocol is two to three hours long, during

which time the paramedic becomes much like the patient’s

personal health coach. “Hospitals don’t have that kind of time

to spend when they discharge patients,” said Dr. Tan. “These

paramedics ensure that when they’re done working with them,

the patients are able to tell them not only what medicines they’re

taking but why and when they should be taking them.

“Many patients comment that for the first time in their lives with

their disease, they understand the disease process, and why

it’s important to take their medicines, weigh themselves and

follow up with their doctors,” Dr. Tan continues. “These patients

love their medics and the attention, and they’re extremely

appreciative.”

The APPs love the program as much as the patients. Dr. Tan was

concerned at first that low-key home health visits might not be

exciting enough for the typically action-driven paramedics.

“They’ve achieved a tremendous sense of accomplishment and

personal satisfaction seeing their patients improve over time, and

it’s a great feeling to know that they had a hand in educating

these patients on their disease process,” said Dr. Tan. “They just

truly care so much about these patients that they want to help

however they can.”

That help extends beyond patient education to perhaps even

saving lives. During a recent meeting Dr. Tan asked the six APPs

to raise their hand if they had experienced even one patient

encounter that didn’t involve some type of medication error. “No

one raised their hand,” he said. “One paramedic discovered a

patient who was taking Metoprolol (typically used to treat high

blood pressure) instead of the Metformin he needed for

his diabetes.”

The paramedics have found unique methods to help patients

stick to their correct medication regimen, including color-

coding the lids with markers. “They’ve found serious errors and

oversights, and by simply helping patients understand what the

drug is, why they take it and when to take it, compliance is much

better,” said Dr. Tan.

Of the 25 patients enrolled in the program, 80 percent remained

out of the hospital during the first 30 days after discharge.

Barnes-Jewish Hospital has responded positively to the program

as well. Nurses consistently relay to program employees how

much patients love the interaction and their visits.

“On his 30th day when he was exiting the program, one patient

even asked if we would still come visit him,” said Dr. Tan. “We’re

looking forward to enrolling more patients in the program and

making a positive difference in their lives.”

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