Community Paramedic Primary Care Project

Problem Statement Barriers to successful chronic disease management – Lack of transportation for follow up – Multiple medications from multiple doctors – Failure to recognize symptoms – Lack of support for healthy lifestyle choices – Limited access to healthy food options

Problem Statement Diabetes Management – Access to healthy foods – Nutrition education – Free/low-cost exercise programs – Glucose testing supplies/education

Problem Statement Cardiovascular Disease Management – Medication education/reconciliation – Blood pressure control – Weight assessment and measurement – Smoking cessation support

Pilot Program – Before HealthRise

Community Paramedic from St. Paul Fire Congestive Heart Failure Patients at Regions – Discharged without traditional home care

Pilot Program – Before HealthRise Home visits by CP - 2x/week for 4 weeks – Physical assessment – Medication reconciliation – Patient education and resource referral – Home safety check

Pilot Program – Before HealthRise Enrolled 13 patients to-date Lessons learned – Mechanics of data exchange and communication – Important role of primary care – Education for healthcare on role of Community Paramedic

Focus: Underserved with Diagnosis General PopulationIndividuals At Risk Individual Decides To Seek Care Arrival At First Point of Care Arrival at Higher Level CHC or DH Definitive Diagnosis of Disease Treatment of Disease Preliminary Diagnosis Long Term Management of Disease Intervention Point 1: Targeting those w/NCD, in treatment but NOT controlled

HealthRise Grant Project Embed the Community Paramedic into primary care clinic – Identify patients who may benefit from home based care between clinic visits St. Paul residents who are traditionally underserved by health care resources – Patients of the East Side Family Clinic

East Side Family Clinic Demographics # Dx with Diabetes# Dx with CVD TOTAL Male Female White4241 Asian35136 Hispanic78943 African American25427 American Indian212 Other Race686 Non- English Speaker30%- 65% Low Income (↓200% federal poverty level)97% UninsuredApprox. 50%

HealthRise Grant Project Home visit by Community Paramedic – Patient assessment – Education for patient and families – Medication reconciliation – Home safety assessment – Connections to community resources

HealthRise Grant Project Collaboration with Community Health Worker – Bilingual CHW(s) to work alongside CP – Attend select home visits – Serve as liaison for patients

HealthRise Grant Project Focus on the primary care clinic – Address gap in care coordination we discovered during our pilot program – Increase emphasis on clinic based care compared to frequent use of emergency room

Project Objective Objective 2 Target PopulationPrevalence Estimate of the Problem in Target Population Percent increase in goal attainment Number of patients to meet clinical goal 1913 patients with diabetes 48% patients outside clinical A1C target 918 patients outside clinical A1C target 10% 92 patients meet A1C goal 155 patients with CVD 37% patients outside clinical LDL goal 57 patients outside clinical LDL goal 20% 11 patients meet LDL goal

Intervention Activities Community Paramedic partner with primary care team of East Side Family Clinic – CP works alongside clinic staff to identify patients – Team based care planning and follow up – Home visits between primary care visits – Needs assessment and resource connections

Intervention Activities Community Paramedic partner with primary care team of East Side Family Clinic – Community Health Worker(s) assist with patient education, advocacy, support and language/cultural interpretation – 1-2 visits per week for one month Visits tapered during grant period Enrolled for duration of grant program

Impact on NCD in St. Paul Care for patients outside target health measure (A1C, LDL) Support holistic approach to care including home visits and follow up Bring primary care into the home through partnership between CP and primary MD

Major Milestones Anticipated in 2015 Hire Project Coordinator (0.8 FTE) by October Develop workflows, patient identification and consent process Convene Steering Committee to include clinic, hospital, fire department staff, program patients and community members

Major Milestones in Early 2016 Identify and schedule first home visit by January 31, 2016 Hire second Community Paramedic (0.5 FTE) – By January 2016 Hire Community Health Worker(s) (per diem) – By March 2016

Our Team Team MemberAffiliationTitle/Role Tia RadantRegions HospitalGrant Manager Lauren HalvorsenRegions HospitalGrant Coordinator Dr. Aaron BurnettRegions HospitalProject Medical Director Ann MajerusSt. Paul Fire DepartmentCommunity Paramedic Matt SimpsonSt. Paul Fire DepartmentAssistant Chief of EMS Dr. Lynne OgawaWestside Community Health ServicesPrimary Care Physician Chris SingerWestside Community Health ServicesChief Operating Officer Community PartnersVariousSteering Committee Members

Community Paramedic Primary Care Project