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

2. 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. 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. 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. 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. 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. 7 Common Response Symptoms  Respiratory Distress  Uncontrolled Pain  Unresponsive  Falls  Chest Pain  Bleeding

8. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 19 Questions?