Ridgeview Medical Center Paramedics
Help Make Transitions to Home Safer

Ridgeview Medical Center is an ICSI member and a participating hospital in the RARE Campaign to reduce avoidable hospital readmissions. This article first appeared in the January 2013 issue of the campaign’s newsletter, the RARE Report. Learn more about the campaign.

Easing the transition to home is one of the five key areas known to reduce avoidable readmissions and is critical to ensuring that patients spend more nights at home in their own beds. Among the challenges patients face are multiple medications, uncertainty about follow-up care, and coordination with multiple providers, all while trying to recover from an illness or procedure. Home visits like those by Ridgeview Medical Center’s paramedics help ensure patients are on the road to recovery, not back to the hospital.

Pictured at right, paramedic Sara Burton reviews medications with a Chaska patient.

After learning about Dr. Eric Coleman’s Care Transitions Intervention program, Ridgeview Medical Center’s RARE team became passionate about the role that a transition coach could play in helping patients navigate transitions in care. Ambulance medical director Dr. Kevin Sipprell envisioned using the unique skill set of paramedics to fill this role. Although there is significant variability in demand for emergency medical services, it is staffed for peak utilization, creating an opportunity to better utilize the inherent down time.

“Paramedics are comfortable going into someone’s home, they are already out in the community, they frequently communicate with providers, and are proficient with algorithms,” Sipprell noted. There would also be little additional expense.

Armed with the knowledge that the discharge plan is not consistently followed once the patient has transitioned back into the home, Ridgeview Medical Center developed goals and guidelines and began using paramedics to perform home visits in late summer 2012. The purpose of the paramedic home visits is to establish and/or re-establish the hospital discharge plan with the patient within 48-72 hours of discharge. Four paramedics were trained initially, with the goal of adding more paramedics as the program expands.

The program has four specific components:

• Medication reconciliation
• Coach disease-specific self-management skills
• Review disease-specific symptoms that might occur and provide guidance on what to do if experiencing certain symptoms
• Preparation for the follow-up visit with patient’s primary care provider to ensure the patient is aware of the visit, transportation is arranged and topics to discuss are highlighted

The program is targeted at patients with three high-risk readmission diagnoses: heart failure, pneumonia and chronic obstructive pulmonary disease (COPD). Patients also need to be discharged to a home within the Ridgeview Ambulance service area, and be without home care services. The patient’s primary care provider must practice with Ridgeview or an affiliated system. Prior to discharge, the patient is informed about the potential follow-up home visit and told that the paramedics will arrive in an ambulance.

Julie Burkhardt, Ridgeview’s performance improvement coordinator, noted that reconciling the medications the patient is actually taking with the discharge medication list is a key element of the program. “Medication discrepancies have been identified on a majority of the visits. Some of these discrepancies involve disease-specific therapies that are critical to maintaining a healthy state,” she said. In fact, Ridgeview identified medication discrepancies in 75 percent of the visits.

It is too early in the process to determine the program’s impact on readmissions, but patient satisfaction with the program has been very high. Ridgeview Medical Center has been able to create a value-added patient experience at no additional cost.

To learn more about the program, email Julie Burkhardt or call (612) 581-7062.