House Calls: Navigating the Slippery Slope Between Hospital & Home

Among sweeping changes underway in U.S. healthcare is a brighter spotlight on patients’ transitions from hospital to home. What can be done to reduce readmissions during these vulnerable periods and possibly save billions of dollars in the process? Increasingly, an answer lies with mobile integrated teams of providers, often led by paramedics, who take healthcare right into patients’ homes.

If David Glendenning, EMT-P, had any doubts about the mission of the community paramedic program he helped organize in Wilmington, N.C., with New Hanover Regional Medical Center (NHRMC), they were dispelled four years ago, when he entered the apartment of his first patient, a man with congestive heart failure. “The thing I remember most is where he had stored his injectable medications,” he says. “Instead of putting them in the refrigerator as directed, the patient had stored them in the freezer. They were frozen solid.”

Glendenning is part of a growing wave of paramedics, advanced practice nurses, physician assistants, pharmacists and other community health workers who are traveling to newly discharged patients’ homes to provide 24/7, non-emergency care. Often working as part of emergency medical services (EMS) systems, their task is not just to deliver point-of-care treatment—thus taking the pressure off of overloaded 911 systems—but to educate and steer patients to other services and professionals they might need. The goal is to keep these high-risk individuals, many with chronic cardiovascular disorders, from returning short-term to the hospital. Pivotal to that effort are the observations these feet-on-the-street professionals make (for example, a box of pepperoni pizza on a patient’s kitchen counter) and the questions they ask (“How are you doing with your medications?”).

“We provide a unique service that helps to fill in the gaps for patients,” says Glendenning, education and outreach support officer for NHRMC-EMS. “We’re not just paramedics, but part of a comprehensive team of case managers, pharmacists and others who provide services the patient may be eligible for but not aware of.” Among the first programs of its type, the North Carolina initiative also has a solid track record. As shown in the figure at right, during a six-month period in 2014, the 30-day readmission rate for the 76 patients who were part of the program was 9.2 percent, compared to 22.2 percent for the parent hospital. The number of readmitted patients with congestive heart failure: zero.

Community paramedics also have a geographic and socioeconomic rationale. According to the Centers for Disease Control and Prevention, in 2017, 15 percent of Americans lived in rural and remote areas. Yet, only 11 percent of the nation’s physicians practice there and rural physician shortages have been documented for 85 years (Virtual Mentor 2011;13[5]:304-9). Mobile integrated programs help address that imbalance by providing an effective at-home alternative for patients who are released from acute care but afterwards have little or no access to check-ups, monitoring and prevention programs. The same principle applies to patients who are discharged to homes in economically distressed neighborhoods—even though they may live only 10 or 15 minutes from the hospital.

Economics as the driver

What’s stoking interest in the home care model is, in a word, economics. With MACRA and bundled payment models rewriting the healthcare rulebook, providers realize they need to broaden their focus from episodic to continuum of care. And no area comes into their crosshairs faster than the slippery period from hospital to home. Here, patients are at their most vulnerable as they grapple with complex and changing care regimens, particularly with medications. Up to two-thirds of hospital readmissions have been traced to nonadherence and adverse side effects of drugs (Ann Intern Med 2003;138[3]:161-7).

A recent study of an insurer-initiated care transition program based on medication reconciliation for high-risk patients led by pharmacists via home visits and telephone consultation found that people in the intervention group were 50 percent less likely to be readmitted within 30 days of discharge than those in the control group. For cardiovascular patients, the risk of readmission was 5.3 percent compared to 9.2 percent for the control group. What’s more, the study reported that the pharmacist-driven program saved two dollars for every one spent (Health Aff [Millwood] 2016;35[7]:1222-9).

“MACRA requires us to stay interested in our patients,” says Jason Stopyra, MD, assistant professor of emergency medicine at Wake Forest Baptist Medical Center, and medical director for the Randolph County, N.C., Department of Emergency Services. “It means we’ll have to form partnerships with all our patients and develop approaches for even the most difficult ones,” adding, “Decision-makers will come to realize that putting money into preventive strategies will far outweigh any penalties.”

Concierge approach to patient care

North Texas Specialty Physicians (NTSP), an independent practice association serving Fort Worth and surrounding counties, acted decisively in 2010 to minimize the bundled risk it bears for healthcare utilization by its 60,000 Medicare Advantage members. NTSP contracted with MedStar Mobile Healthcare to reduce emergency department visits and unnecessary hospital admissions through visits by MedStar’s specially trained medics and case managers to the homes of patients enrolled in the program. During these visits, medics become aware of the patients’ disease management and coping skills, frame of mind and support networks. Should an individual become short of breath at 2 a.m., the same medic may be asked to intervene with medication at the home, thus preventing a trip to the hospital.

“We think of it as a concierge approach to chronically ill patients,” says S. David Lloyd, MD, MBA, medical director for Silverback Care Management, the care management division of NTSP. “And one of the reasons the program is so successful is that we partner with paramedics, who have the kind of credibility which [other providers] going into patient homes might not.” In 2016, 75 percent of the program’s 45 members had no hospital admissions within 30 days of enrollment, he says.

The number of mobile integrated healthcare programs has grown from four in 2009 to 260 today, according to Matt Zavadsky, director of public affairs for MedStar and president-elect of the National Association of Emergency Medical Technicians. For traditionalists like Medicare, which continues to cover only ambulance transport to the hospital, Zavadsky points to Agency for Healthcare Research and Quality data and offers this advice: “If you would pay us to keep people out of the hospital, not only would you get better outcomes, but you would save a ton of money by avoiding the average $10,500 expense of admitting each patient.”