House-call paramedics work to cut hospital readmissions in Glendale pilot project
Glendale Fire Department Paramedic Gilberto Mejia has a job that’s a lot different from the work his 911 colleagues back at the station house do.
Instead of responding to medical emergencies, Mejia works to prevent them by making house calls to newly discharged cardiac patients.
"We've been trained to assess the environment in which they're living; any psychological issues they may be dealing with ... how they're managing their condition," he says.
The 11-year fire department veteran is the lead paramedic in a new pilot program that involves the Glendale Fire Department, the UCLA Center for Prehospital Care and Glendale Adventist Medical Center. It's a year-long experiment that's working to keep congestive heart failure patients from being readmitted to the hospital within 30 days of discharge.
"I think there will be a lot of patient satisfaction," says Lou Meyer of California's Emergency Medical Services Authority, one of the state agencies overseeing 13 paramedic pilot projects statewide.
Making sure newly discharged patients stay healthy has become a goal of hospitals nationwide; under the Affordable Care Act, those that don't face hefty federal penalties. In 2015, Medicare fined half of the nation’s hospitals a combined $420 million dollars for readmitting too many patients within a month of being hospitalized. Among them: more than a hundred hospitals in the greater Los Angeles region, including Glendale Adventist.
A high readmittance rate
For hospitals aiming to cut readmission rates, congestive heart failure is especially problematic, says Dr. Steve Rottman, a UCLA professor of emergency medicine and medical director for UCLA's Center for Prehospital Care.
"Roughly a quarter of patients who have congestive heart failure, once they’re discharged, end up being readmitted within a month," he says.
About two-thirds of those readmissions, Rottman says, happen within the first week a patient goes home.
"And within that first week," he adds, "nearly half [of the readmissions] happen within the first three days after they’re discharged."
That's happened to Lucy Colon, a 59-year-old mother and grandmother. Before getting a pacemaker implanted in her chest at Glendale Adventist in mid-December, Colon says she had been frequently hospitalized for congestive heart failure. But during her most recent hospital stay, she was offered a chance to get some additional at-home support from Mejia, which she says she eagerly accepted.
"I was so happy to meet [Mejia] and hear about this program," says Colon, during a recent two-and-a-half hour house call held inside her RV at a Sunland mobile home park.
Along with reviewing Colon's diet and fluid intake, Mejia checks her blood sugar level; measures her pulse; takes her temperature; weighs her on a portable scale; and runs an EKG on her heart. All appears normal.
Next he reviews Colon's medication regimen. Like most congestive heart failure patients, she is prescribed a slew of different drugs.
"The biggest thing is, do they know when and how to take [their medications]," Mejia says. "And are they organized about it, so they're not overdosing or underdosing?"
When that’s done, Mejia calls a local pharmacy about filling a prescription Colon needs. He calls her health insurer and a primary care doctor to arrange for a follow-up visit. And he promises to coordinate with her home health team.
"Can you change a light bulb?"
But that's not all he does on his patient visits.
Sometimes Mejia takes on non-medical tasks during these house calls. One time, he says, he agreed to deliver an immobile patient’s rent check to the post office. And before he left the man’s house, Mejia says, there was another request: "He says, 'Can you change a light bulb?' I said sure!"
For the Glendale pilot program, Mejia and his colleagues underwent nearly four weeks of specialized study that included almost 100 hours of core community paramedicine training at UCLA's Center for Prehospital Care, Rottman says.
Following that training was nearly a week of advanced studies in cardiac physiology and pharmacology, capped with another four days of clinic work in the hospital alongside cardiac doctors and nurses, he says.
The program requires both patient consent and a parmedic home visit within 72 hours of the patient's discharge, Rottman says.
"What we're trying to do is to get into the house during the patient's most vulnerable time ... to prevent a re-hospitalization," he says.
Colon is among nearly 40 patients seen by paramedics since the pilot began in September. So far, Glendale Adventist officials say, only two have been readmitted to the hospital for heart-related issues.
Still, some have concerns.
"They’re trying to provide minimal training for paramedics to basically replace what should be home care nurses who are more highly skilled and actually have the ability to look at a greater number of issues that are relevant to a patient’s care," says Vicki Bermudez, regulatory specialist with the California Nurses Association.
Dr. Harry Balian, chairman of Glendale Adventist's cardiology department, disagrees. In addition to using paramedics to help care for patients in the pilot project, he says home health nurses continue to be sent out for those who need them.
"You can never have enough follow up with a patient – it’s multiple layers of protection," says Balian.
Lucy Colon, meanwhile, says she welcomes the extra medical help, which she hopes this time will keep her healthy and out of the hospital for good.