Community Paramedic Intervention for the Reduction of Emergency Department 72-Hour Return Visits

Abstract
Purpose. To determine the processes required for a Community Paramedic home intervention 24 hours after Emergency Department discharge to reduce 72-hour ED return visits, while evaluating patient satisfaction and compliance.
Methods. The study took place in a critical access hospital Emergency Department and the surrounding service area. ED providers referred subjects to the study based on suggested criteria identifying increased risk of an unplanned 72-hour ED return. All subjects were discharged home from the ED and above the age of 18 years. Suggested criteria for referral included: no primary care provider, insured by Medicaid, Medicare or not insured, had one or more previous ED visits within the past two months. Exclusion criteria include not being discharged home, live over 80 miles from the discharging hospital, or were under the age of 18 years.
A home visit was performed with the participants within 24 hours after discharge to explore the processes needed, and the feasibility, of a community paramedic visit to mitigate circumstances for a 72-hour unplanned return visit. Of the twelve patients who were referred to the study, five consented to participate. The home visit was performed utilizing a template for reducing unplanned hospital readmissions, the Better Outcomes by Optimizing Safe Transitions (BOOST 8P’s) Screening Tool. A post-visit survey explored patient satisfaction and insight to the program.
Results. Several themes were identified as useful areas of focus for the community paramedic home visit. These include reviewing side effects of home medications, confirming a follow-up plan with primary care, the need for a cohesive connection with primary care for order clarification, need for mobile medical record applications, and the need for pre-printed health education materials catered to the patient diagnosis.
Service delivery opportunities include streamlining patient navigation, education, preventative health-care maintenance, on-site treatment without transport, identifying and addressing patients with high ED utilization, and post-discharge follow-up.
Through interviews with local and state level representatives, suggestions were created for establishing a community paramedic program. These include state-level changes for education, certification and protocol development, legislative changes to allow EMS reimbursement for non-transport services, alignment with regional health systems for a cohesive approach to care, and funding options for program startup.
Discussion. System hurdles in program development include limitations in reimbursement opportunities in the Commonwealth of Virginia, lack of detailed community paramedic role and education through the State Office of EMS. Potential solutions include partnerships with regional health systems for medical direction and potential Accountable Care Organization contractual relationships for reimbursement.
Further research is needed to understand the implications of a community paramedic process in the rural health setting. Existing data has primarily surrounded urban communities with a minimal focus on the ED 72-hour return rates. However, the limited data that does exist shows promise for the potential impact of these programs in a broader sense of healthcare quality.
With grant funding, limiting the financial risk for health system guidance, a pilot community paramedic program can offer the prime opportunity for outcomes research in a rural setting. With simultaneous efforts at the legislative level, the ability to expand EMS reimbursement for such services can help ensure the continuation of the program for years to come.
Next Steps. The qualitative data collected during this study concludes that a community paramedic program, in a broader sense of healthcare delivery, is very feasible. As a result of this study, numerous conversations and relationships were developed at the local and State level, attracting interest from a non-profit organization with a desire to fund the development of a rural community healthcare worker program. A committee of stakeholders has been organized and is actively planning for development of a home-health initiative with the financial backing of a non-profit grant-making organization. Currently, this organization funds a full-time social worker position for a rural county in the research hospitals service area. Conversations are in place to propose that the local health system becomes the clinical leader for this endeavor, offering oversight and human resources, while the financial risk is absorbed by the grant funding organization.
Keywords: community paramedic, rural health, emergency department return visits, logic model, mobile integrated health paramedic, care coordination