Population Health Initiatives: Community Paramedicine Program Lauren Parker, Administrative Fellow

Phases for Objectives Phase 1: Focused on Full-Risk CHF/Heart Failure Patients within the CIN Violet, Whitehall, Truro Township Fire Departments; Metropolitan Emergency Communications Center (MECC). Phase 2: Other Attributed Members, ACOs, MSSP, Other Primary Diagnoses Phase 3: Underserved Populations 12

CHF Pilot Patient Population – 5-6 Patients per Community Paramedic (Violet, Truro, Whitehall) – Primary Diagnosis: CHF/Heart Failure – Attributed within Population Health/CIN – Can be referred from CHF Clinic, Inpatient, or the participating Fire Departments – Residence within Violet, Whitehall and Truro Townships Services – Initial 1-2 hour visit assessment – Additional hour visits for monitoring and as needed – Time of dispatch to completion: 1.5 hours – Referrals to Home Care, Behavioral Health, Social Services, Follow-up with PCP or CHF clinic etc., if needed 3

Training and Orientation 4 RotationHours Street Medicine – Homeless Coordinator (Ben Sears)16 Mobile Coach Social Work/Case Management8 Mobile Coach16 Hospice32 Hospital Based Social Work/Case Management16 CHF Clinic16 Shadow the PA16 Patient Advocate8 Home Health Nursing16 Emergency Department with Physician16 Primary Care Physician’s Office8 Diabetes Clinic8 Mental Health Center (NetCare (Franklin Cty)/Mound Builders(Licking Cty)/New Horizons (Fairfield Cty)8 Odds & Ends8 Total192 Community Paramedic Mentorship40 Grand Total232

Inventory of Services Physical Assessment, vital signs, biometrics Social assessment, quality of life assessment, mental health evaluation Environment check / home safety / fall risk Respiratory assessment Point of care testing Referrals if needed to home care, behavioral health, SNF, extended care, dietetics, etc. Health coaching Medication reconciliation Pain management Infusion needs Communication with providers, care managers, home care, social workers, etc. Scheduling appointments, setting up with a primary care physician, follow-up visit, etc. Arranging transportation to appointments Patient education, reviewing post- discharge instructions Advanced directives / goal setting Such other services within the scope of the Paramedic’s licensure as requested by MCHS from time to time 5

Toolbox of Essential Equipment for November 1 st Pilot 6 StethoscopeCell phone Pulse OximeterLaptop Point of Care Tool (K+ and effect of diuretics)/iSTAT Omega Car ScaleA1C Monitor (1-2) Thermometer Glucometer AED/Monitor Blood Pressure Monitor

Post Phase 1: CHF Pilot Metrics will be evaluated for pre and post pilot Gaps will be addressed Eventually continue into the Phase 2 Action plan covering additional attributed lives, hiring and training additional Community Paramedics, developing additional protocols and broader more robust scope of practice 7

Evidence-Based Metrics to Track No shows at CHF Clinic Frequent flyer list: Pre and Post – Define frequent flyer list Reduction in ED Visits Reduction in total cost of care (because of THIS program) Reduction in Readmission (30 days) Primary Care Physician utilization Medication Inventory Unplanned acute care use within 6 hours Satisfaction with Community Paramedic Behavioral Care Provider Use, Social Service Provider Use Response time Metrics will be shared for review 20

Documentation Referral “APP” – Available for quick electronic referrals to Home Care, Hospice and Care Choices Care Evolution: Social Assessment – Used to track patient progress, update records with any episodes or changes, identify gaps in care, behavioral health evaluation, visible to physician offices, medication compliance, helpful for metrics/tracking Fire Department EMR: Physical Assessment – Vital signs, blood pressure, weight, medications, etc. 9

Case Management Referral Process 10

Thank You! Questions… 11