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Medstar, Hospitals Collaborate to Care for Patients After Hospital Stay


Medstar, Hospitals Collaborate to Care for Patients After Hospital Stay

Helping patients remain on track with physician directions and medications after a hospital stay is key to their continued improvement, and is the single most important factor in preventing readmission or emergency departments after discharge.  A unique program in Macomb County hopes to provide a new tool in helping patients understand and follow their doctor’s orders, and support them at home. 

Medstar, along with Henry Ford Macomb and McLaren Macomb hospitals, have spent the last 18 months envisioning ways in which paramedics can work with hospital and primary care physicians, clinical case managers, and patients to solve the issues that frequently cause patients to return to the hospital after being discharged. The result of their efforts is the “Mobile Health Paramedic” program, operated by Medstar. Fully funded by the hospitals, the 180-day trial program provides specially trained paramedics who visit patients in their homes immediately after leaving the hospital, and two to three times each week for a month. 

“There are several similar programs across the country right now looking at how paramedics can help support other healthcare providers with patient and physician engagement from the home,” said Susan Burkhardt, Medstar Vice-President of Healthcare Integration.  “By having our Mobile Health Paramedics in the home immediately after discharge, we can review the physician instructions with the patient and family, check to be sure they have the prescribed medications, identify potential medication interaction problems, and set up a schedule to visit the patient to help keep them on course to improvement.”

In developing the program, the hospitals and Medstar convened healthcare stakeholders from hospitals, community physicians, home health agencies, social workers, and paramedics to examine common causes of patient readmission, and structured the pilot program to address them.  Medstar’s Chief Executive Officer Kolby Miller said “Between not completely understanding discharge instructions, not picking up or taking newly prescribed medicine, or simply not having good water or a comfortable pillow at home, many patients wind up back in the hospital shortly after being discharged.  By visiting them immediately and regularly after their visit, we can keep them on track, and communicate directly with their physician if something changes or the patient has other concerns.”

Barbara Rossmann, President and Chief Executive Officer of Henry Ford Hospitals wholeheartedly supports the program. “We do our absolute best for patients when they are in the hospital, but realize that the patient home environment may lack the structure or support to keep on track with their discharge instructions, or follow-up care with their physicians. The Mobile Health Paramedic program may be the perfect link between the hospital, physician, and the patient at home.”

The development team for the program included physicians, nurses, case managers, and administrators from each of the hospitals, as well as clinical and organizational leadership from Medstar.  “By engaging all of the stakeholders in the post-discharge experience, we identified frequent issues, challenges, and opportunities to make a difference, and designed the program to specifically address them with the patient and their family, said Dr. David Pinelli, D.O., Vice President of Medical Affairs and Chief Medical Officer at McLaren Macomb. “Knowing that our in-house care teams have to rely on the patients or family members to tell us what is occurring in the home, we all recognize that many of our treatment decisions may not be understood or followed.  This program directly addresses those issues.”

The initial pilot program, approved by both the Macomb County EMS Medical Control Authority and the Michigan Department of Community Health EMS Division, focuses on a limited number of patient conditions, and is limited to patients who live Medstar’s service area and have a participating primary care physician.  “Throughout the planning process, we have recognized several areas in which this type of program can make a difference for patients after hospitalization, however, we limited the scope and size so that we could properly collect data and evaluate the impact of the program,” Miller said.  “We visited other programs outside of Michigan, and there are several examples of in-home support and care being provided by paramedics. With our structural linkage and clinical engagement with our health system partners, we know that there will be multiple opportunities once the pilot is completed.”

The Mobile Health Paramedics program includes extensive training for the paramedics that includes expanded clinical training related to the patient diagnoses included in the pilot, additional assessment techniques, and training related to patient counseling and feedback.   The paramedics are also required to spend clinical time in both hospitals case management and clinical care programs, and receive training on primary care physician patient care needs and documentation.  Nicole Monpetit, one of the three Medstar Mobile Health Paramedics, said “After treating patients in the emergency setting for several years, this is a great opportunity to make a real difference in their care from a new approach.  So many of the patients that we transport to the hospital are going in only because they have not done well with their care at home, or don’t know what to do when their medications aren’t working correctly or run out.”

Within the first month of the program, the Mobile Health Paramedics have had a significant impact on their patients. One patient, an elderly man who is living alone for the first time, was found to have multiple medications in his home that were outdated, prescribed to someone else, or were not used in his current care plan, but were still being taken occasionally.  Within four days of being discharged, the mobile health paramedics noted that the patients weight was increasing due to fluid, which complicates his breathing.  “Initially, we were able to able to remove the medications from his home,” said Burkhardt. “After we discovered fluid retention, the Mobile Health Paramedic made contact with the patients physician from his home, and was able to get a prescription changed, which completely resolved the issue by our next visit.  The patient also requested that his mobile health medic attend his first physician appointment with him, which really demonstrates the value of our involvement.”

Another patient was not compliant with hospital discharge instructions due to an understanding barrier at home, and a lack of family engagement in the necessary steps to improve the patient’s health.  By contacting community resources including a mental health practitioner and social worker, and securing a few in-home assistive devices, the Mobile Health Paramedics were able to gain both patient engagement and active family support, both which had been missing and largely responsible for several prior hospital admissions.

The Mobile Health Paramedics meet the patients while they are still in the hospital, based on the referrals of the physicians treating them.  The program is offered to the patients, and if they enroll, the paramedics gather the patients medical history, current and previous admission and treatment programs, and prescribed medications. The hospital physician provides the target clinical signs that he or she expects the patient to be within to the paramedics, as well as contact information for family members and the patient’s primary care physician. 

When the patient is discharged, the Mobile Health Paramedics visit the patient in their home within four hours of discharge, complete a full patient assessment, medication reconciliation, and home safety/wellness check.  They insure that the patient understands their discharge instructions, make sure they have the proper medications and treatment aids, and schedule their routine visits for the coming weeks.  Once the initial visit is complete, the medics return to the patients home every other day to assess them, check medications, confirm physician appointment scheduling and transportation, answer questions, and help the patient with care related tasks. 

If the patient feels that they need the Mobile Health Paramedic outside of the normal visit schedule for issues related to their care, they are encouraged to call, as the paramedics will visit the patient’s home at any time during the day or night. By agreeing to participate in the program, the primary care physicians agree to accept direct calls from the mobile health medics at any time.  In addition to faxed reports of every visit, primary care physicians are also provided with access to the Mobile Health Electronic patient information system, which allows them to view the Mobile Health Paramedic assessments, ECG readings, vital signs, and other information.

“Within the course of the pilot, we will be able to provide an analysis of the impact of our Mobile Health Paramedics on patient’s health status and frequency of emergency department utilization and subsequent readmissions, Miller said.  “Along the way, we expect to provide very valuable services, with a healthy dose of individualized care and compassion for all of the patients in the program.”


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