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Home Visit: Transition to Home Now Safer Kevin Sipprell MD Julie Burkhardt MS, RN RARE Action Learning Day Thursday, November 8, 2012.

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Presentation on theme: "Home Visit: Transition to Home Now Safer Kevin Sipprell MD Julie Burkhardt MS, RN RARE Action Learning Day Thursday, November 8, 2012."— Presentation transcript:

1 Home Visit: Transition to Home Now Safer Kevin Sipprell MD Julie Burkhardt MS, RN RARE Action Learning Day Thursday, November 8, 2012

2 Ridgeview Ambulance Service 730 Sq Miles/7 counties 130,000 population 64 paramedics 35 EMTs Ambulance Coverage – 8 during the day – 5 overnight – 2 Volunteer 10,000 calls – 30% non-transport – 18% interfacility

3 Filling the Gaps EMS staffs for near peak utilization – There is significant hour to hour and day to day variability There is inherent downtime in EMS What else can they do during this time?

4 Ambulance Offers Unique Skill Set Medically trained staff Comfortable going into peoples homes Already in community/service area Proficient working with algorithms Frequently communicate with providers Assures no added expense

5 Gaps meet RARE… Project Goals and Strategies Enhance the role of the paramedic Reduce avoidable readmissions! Ensure discharge medication plan is the home medication routine Coach disease specific self- management skills Afford the patient a value- added experience

6 Implementation Activities Identified 3 high risk readmission diagnoses: CHF, PN, COPD Trained 4 medics as the core group; will roll out to additional medics as program expands Rolled out to RMC clinic patients/providers first; intend to add other clinic(s) in near future

7 Implementation Activities Educate patient prior to discharge of potential visit Schedule visit hours post-discharge but prior to follow-up visit with Primary Care Provider (PCP) Acceptance of program and potential phone calls from medics by PCPs

8 Challenges & Outcomes Patients must reside in RMC ambulance service area Notification of patients that medics will arrive in an ambulance (alarm neighbors!) Visit length goal at 40; currently 60 or more Restructured/refined checklists to only most essential elements to reduce visit to 40

9 Lessons Learned & Suggestions Change paramedics mindset from a role of treat/transport to that of a coach in self-care skills Coaching is likely much more effective in the home – Visualize foods re: sodium – Seeing weight chart/scale Med Reconciliation is bigger than world hunger!! – Med Discrepancies were found on 83% of the visits


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