Utilizing Advanced Practice Paramedics to Reduce Hospital Readmissions Presented by: Kevin Yarrow

1. Utilizing Advanced Practice Paramedics to Reduce Hospital Readmissions Presented by: Kevin Yarrow Senior General Manager VITAS Innovative Hospice Care of Dallas

2. CALL 911! Patients and Families often panic & call 911 when: • There is a sudden change in condition • Exacerbation of existing or new symptoms • Caregivers are unfamiliar with hospice services

3. EMERGENCY DEPT. Patients experience: • Long (and uncomfortable) wait times in the ED • Patient receives either palliative treatment they could have received at home, or unwanted aggressive treatment • Readmission to the hospital instead of their preferred setting for care (at home)

4. ALTERNATIVE TO 911 If the patient had called hospice first: • Potential delays in on-call nurse arrival • Enduring uncomfortable symptoms for longer period of time • Additional delays after nurse arrives while waiting for medication, infusion supplies or other equipment to palliate symptoms

5. Hospice/Hospital Impact • Lost revenue to hospice due to revocation for aggressive treatment • Emergency Department expenses paid by hospice if patent remains on service • Reputation affected for failure to manage patient ‘s care adequately at home • Potential penalties levied on hospitals for readmission within 30 days

6. Paramedic Solution • Paramedic can often arrive faster than a hospice nurse • Paramedics are trusted by the public to resolve emergencies quickly • Paramedics carry medications (including IV therapy) and equipment not available to responding hospice nurse

7. Common Response Symptoms • Respiratory Distress • Uncontrolled Pain • Unresponsive • Falls • Chest Pain • Bleeding

8. Possible Interventions • Assistance with prescribed meds in home • Injury assessment and assist to bed • Nebulizer treatment • BiPap therapy • Aerosolized pain medication administration • Establishing an I.V. (hydration, meds) • Wound Dressing • High Flow Oxygen • Transport to hospice General Inpatient bed

9. Paramedic Partner Candidates • Local government run paramedic service (i.e. Fire & Rescue) • Private paramedic & ambulance company contracted to provide 911 dispatch/response (i.e. MedStar or AMR) • Private ambulance company with paramedics on staff

10. Getting Started • Identify the paramedic partner that best meets your need • Every jurisdiction (and county) may have their own rules governing paramedics • Customize the program to meet as many of your needs as possible given local regulations.

11. Program Options • If the partner operates within the 911 call center, they may track your high risk for revocation patients in their system and notify you when your patient calls 911 • Your partner may perform “pre-need” introduction visits to your patients • If your partner is outside the 911 system, you may still partner with EMS to defer to your paramedic partner in an emergency

12. Pre-Implementation Steps • Assist the paramedic service to develop a palliative response protocol, or policy (to avoid transport to the nearest ED) • Develop a written agreement between your hospice and the paramedic company spelling out responsibilities, COP/HIPAA language and reimbursement for services. • Coordinate your Medical Director and the paramedic service Medical Director to establish order protocols

13. Pre-Implementation Steps • Have paramedic service extend physician privileges to your hospice physicians • Develop a formulary for medications stocked on the paramedic’s response vehicle. • Establish a step-by-step protocol for dispatch, sharing patient information, communication during the response and written report for patient’s hospice chart.

14. Pre-Implementation Steps • Hospice provides training for paramedics on caring for end of life patients, palliative symptom management and available options to ED transport (Continuous Care, General Inpatient, etc.) • Create a training program for hospice teams • Develop information collateral that describes the program for referral sources and patients/families

15. COP Considerations • Written Agreement with COP language (including hospice retains professional management of the patient’s care, background checks, etc.) • Paramedics (“Vendor”) educated by hospice • Hospice nurse is dispatched along with paramedic & updates Plan of Care • Hospice physician give orders to paramedic for on scene interventions

16. Response Protocol Suggestions • Approval to dispatch required (assuming you are paying per response)? • Face Sheet, DNR, Med List (faxed or emailed to paramedic) • Provide name and cell of the hospice nurse enroute to paramedic • Provide MD on call name and number to obtain on scene orders

17. Potential Challenges • Family also calls 911 (prior coordination with Fire Department EMS supervisor may allow for transfer of care) • If paramedic arrives in an ambulance (vs. a non-transport vehicle) the family may push for transport • Most private paramedics will not respond with “lights & siren” so arrival may be longer than family expected

18. After the Call • Obtain paramedic’s written report. Review in IDT and keep in patient chart • Communicate response activity to the team (if after hours) for follow-up • Communicate response outcome with patient’s Attending and/or other physicians • Track responses and share success rate.

19. Questions?