Partnership aims to cut unnecessary ED use
Model teams paramedic, advanced practice nurse
Executive Summary
Scottsdale (AZ) Health System and the City of Scottsdale Fire Department are teaming up to treat patients at the right level of care and avoid unnecessary trips to the emergency department and hospitalizations.
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In the model, a paramedic from the fire department and an advanced practice nurse from the hospital will take calls to 911 that the medical triage staff determines are low-level complaints that do not require a trip to the emergency department.
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The nurse-paramedic team will also make follow-up visits to discharged patients who may be at risk for readmissions.
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They will be equipped with videoconferencing equipment they can use to consult with behavioral health providers and, when appropriate, transfer patients with mental health problems directly to a provider, eliminating an emergency department visit.
By working together, Scottsdale (AZ) Health System and the City of Scottsdale Fire Department have developed model in which a paramedic from the fire department and an advanced practice nurse from the hospital would treat patients who call 911 but don't need care in the emergency department, provide follow-up assessment for patients who are at risk for hospital readmissions, and transport appropriate behavioral health patients directly to a behavioral health provider, avoiding an emergency department visit.
The initiative grew out of the hospital system's initiative to improve care by meeting regularly with community organizations that provide services to the elderly to collaborate on ways to improve transitions. For details, see the October 2013 issue Hospital Case Management ("Team focuses on needs of the elderly," page 138).
"We are making a lot of effort with our community partners to provide appropriate services at the right level of care," says Karen Vanaskie, MSN, RN, director of case management, Scottsdale Health System.
Representatives from the health system's case management department and the fire department have been meeting for several months to develop the model and are collecting the data they need to make a formal request for funding. The representatives from the fire department are tallying the types of calls that would be appropriate for the initiative and the number of repeat visits the paramedics make in cases that don't require emergency treatment. Hospital staff are compiling data on discharge and return rates and patients with low acuity and behavioral health issues who come to the emergency department.
"We are working together to meet the needs of our community. The hospital needs a way to see that patients with non-emergent needs are not coming to the emergency department, and we need a way to make sure that the 911 system is not utilized for things other than emergent care," says Scottsdale Fire Chief Tom Shannon.
The paramedic-nurse team would work out of a specially equipped vehicle similar to an ambulance and receive referrals from the 911 alarm center based on telephone triage by a medical professional and priority dispatch as well as referrals from the hospital case managers.
When patients call into 911 with low-level complaints that don't require emergency department services, the team would be able to treat them in their home and refer them to a physician network or primary care provider for follow up.
For instance, patients who have a small cut that needs just a few stitches or people who have fallen and need help getting up would be triaged to the team. "We want to provide an alternative to an emergency department visit for patients with low-level needs," Shannon says.
Many of the patients who likely would be treated by the paramedic-nurse team are elderly and call 911 multiple times each month for minor problems, says Assistant Fire Chief Eric Valliere, who heads the fire department's professional services. "A significant number of these calls involve falls. One of the responsibilities of the team would be fall and injury prevention education," he adds.
The team would also receive referrals from hospital case managers who request follow-up visits in the home for patients who are being discharged and have a high risk for readmission. In those cases, the team would check to see that the patients have filled their prescriptions and are taking their medication, check vital signs, and determine if the patient needs additional support such as help with meals or transportation. "My goal is that the case manager in the hospital has someone to alert about a person who might be at risk for readmission and who could check on them for the first few days after discharge. The team would be our eyes and ears in the home and could alert us that we need to set up community resources for the patient," Vanaskie says.
Paramedics already alert the hospital staff when they get a call to a home where the patient needs community resources, such as help with utilities or other support, Vanaskie says. "We want to take a proactive approach so the case managers can refer people they are concerned about and the paramedic-nurse team can identify the need and alert the case managers before the patient calls 911," she adds.
The team also would be educated to deal with people with behavioral health issues and use a secure videoconferencing line to consult with behavioral health professionals on the scene.
"If we can get the patients assessed on the scene, they won't have to be seen in the emergency department and can go right to behavioral health. Our goal is to get patients care in the right destination," Valliere says.
The program would go a long way to optimizing the resources of both the fire department and the hospital, Shannon says.
"A good portion of our community uses 911 and the emergency department as their primary care physician. We are looking at ways to alleviate this problem, prevent some unnecessary visits, and provide the care patients need in the appropriate setting," Shannon says.
