Anyone who has visited an emergency room recently has been confronted with a mass of humanity patiently—or impatiently waiting for medical care. Most are aware that hospital costs are soaring and anyone involved in healthcare is aware of the high hospital readmission rates. UCLA Health System is well aware of these problems, and has taken a proactive stance. It announced on August 31 that the UCLA Center for Prehospital Care has partnered with the Los Angeles County Emergency Medical Services (EMS) agency and the Glendale and Santa Monica Fire Departments to launch two pilot programs designed to cut hospital readmissions, reduce overcrowding in emergency rooms, decrease healthcare costs, promote patient satisfaction, and improve patients’ quality of life.
UCLA notes that the Community Paramedic Pilot Programs expand the current roles of Glendale and Santa Monica paramedics; thus, allowing them to more closely interact with members of their communities. The programs are the offshoot of a report released by the Institute of Medicine a decade ago, which recommended determining alternative methods to deliver healthcare using emergency medical services agencies. That report then resulted in the federal government instructing communities to assess the future of EMS agencies and how they could better provide and expand their services.
“EMS traditionally responds to 9-1-1 calls only. They find a patient with a problem and transport them to an emergency department. The thought was maybe there were other patient care delivery options these very well trained professionals could perform,” explained Baxter Larmon, PhD, an adjunct professor of emergency medicine, director of California State Community Paramedic CORE Education and co-principal investigator of the UCLA pilot projects.
California state law dictates what duties EMS can perform; therefore, it was determined that programs should go through the state Office of Statewide Health Planning and Development, which can run pilot projects outside of state laws and regulations. A request for pilot projects was sent throughout the state and 13 projects, including the two run by UCLA, were approved. UCLA’s are the only projects being tested in Los Angeles County.
The Alternate Transport Program will be launched on September 1 in Santa Monica and within several weeks in Glendale; it allows, with patient approval, the transport of patients with less serious medical complaints to one of several approved urgent care centers for treatment instead of to an emergency room. Wait times are significantly shorter at urgent care centers and ambulances; thus, their crews will be back in service much more quickly. Dignity Health Glendale Memorial Hospital and Glendale Adventist Medical Center are participating in this program, as well as UCLA Medical Center Santa Monica.
Dr. Larmon explained that many calls to 9-1-1 do not rise to the level requiring emergency department resources, and often can easily be handled at urgent care centers. The Glendale and Santa Monica paramedics in the program received additional training from UCLA to aid them in determining which patients would be appropriate for consideration for transport to an approved urgent care center, and which had conditions that would be better evaluated and treated in a hospital emergency department.
“Our primary goal is to reduce overburdened emergency departments receiving patients with minor illnesses or injuries,” noted Dr. Larmon. He added, “Research has shown that wait times in busy emergency rooms can be up to six hours. In our program, we hope patients will be seen considerably quicker than that, which will be better for emergency rooms and patients.”
The second pilot program will be launched in Glendale with Glendale Adventist Medical Center and the Glendale Fire Department. Also launching September 1, it focuses on patients with congestive heart failure who have recently been released from the hospital. Patients would receive a home visit from paramedics specially trained to assess and evaluate their symptoms, ensure they are taking their medications correctly, eating a heart healthy diet and that their home environment is conducive to them remaining healthy enough to continue to stay at home.
Most hospital readmissions for congestive heart failure patients generally occur in the first 48 to 72 hours; therefore, the visits will occur in this critical window, said Steven Rottman, MD, an adjunct professor of emergency medicine and principal investigator for the pilot programs. He explained that the programs are modeled after those conducted in more rural areas, where patients might not live near a major medical facility. He explained that those programs have been proven to be successful.
Approximately 64% of hospital readmissions for congestive heart failure patients occur within seven days, with half of those within the firsts three days, explained Dr. Rottman. He added, “There’s obviously a missing link in the chain of care and that’s what we’re trying to crack with this program,” Rottman said. A patient readmission occupies a hospital bed that is already at a premium. In addition, Medicare is not reimbursing hospitals for these patients and, in fact, is fining medical facilities for readmitting patients with specific conditions such as congestive heart failure within 30 days after being discharged. Dr. Rottman said, “Going back to the hospital is a disruptive experience for the patient and may not improve their quality of life. Anything that we can do to cut costs, save hospital beds and give patients a good quality of life would be a vast improvement.”
Paramedics are experienced in assessing and stabilizing sick patients outside of a hospital setting; during a home visit, they can check vital signs such as blood oxygenation, perform an EKG and receive guidance from a physician consultant on whether an immediate appointment with a primary care physician is required or whether hospitalization is necessary. The paramedics will serve as gap fillers between hospital discharge and the patients’ first follow up visit with their physicians.