As a result of helping a patient who was a frequent emergency department visitor, the KHP Care Management Team identified a new opportunity to work with Lexington EMS. The new partnership is already proving to be a great success.
KHP RN Health Coach Teresa Crowell and Outpatient Care Coordinator/Social Worker Elizabeth Atkins received a referral from the patient’s primary care provider. The older widowed patient has active diagnosis of Congestive Heart Failure, COPD and Hypertension and his failing health made it challenging to care for himself. Teresa and Elizabeth quickly developed a plan that included Wheels transportation, Meals on Wheels, services for bathing assistance, meal prep, housekeeping, medication support and additional medical visits.
After discussing the plan, the patient shared with Elizabeth a local EMTs business card. He said he was given the card because he goes to hospital emergency departments so frequently and the EMT wanted to call Elizabeth to see how their team might be able to assist in the patient’s care plan.
Elizabeth met with two EMT’s that are part of the Kentucky Community Paramedicine Program, focused on reducing unnecessary calls to 911 and unnecessary ED visits. She learned that this particular patient was the 4th highest utilizer in Fayette County, having called emergency services 31 times between November 2017 and March 2018. In all 31 calls, the patient’s lowest oxygen saturation was 94% and on the last response, his blood pressure was 126/80 and heart rate was 74.
We attempted unsuccessfully to get the patient placement in a short term skilled facility for PT, nursing, education on medication use, and self-care. However, the new working relationship with EMS helped make placement a reality.
The patient developed a UTI, called 911, and our partner EMT heard the call. He went to the emergency department with the information needed to get the patient admitted. And the tag-team effort allowed Elizabeth to work with the hospital case manager to get a skilled care placement.
Following discharge, Elizabeth was able to coordinate a short term stay at a family member’s home, begin home health, and get needed home equipment. She has also been able to visit and discuss future housing and other personal care options.
Since KHP’s new relationship with the Community Paramedicine Program, this patient has only accessed emergency services once, and that was the day he was actually admitted.
Breaking the habit to call 911 is hard. Just a few weeks ago, the patient’s son called Elizabeth for help. The patient was attempting to call 911 because his nebulizer broke. She was able to intercede, calling the patient to deescalate the situation, then contacting his provider’s office to get an order and a DME company to ensure prompt delivery. In the meantime, the son also called the EMT to provide an update and he made a quick visit with the patient to provide education and support until the new equipment could be delivered.
Now the Community Paramedicine Program is reaching out to KHP when they think one of their patients might be a covered life.
Interesting Facts About Fayette County’s Community Paramedicine Program:
- In 2009, there were 29,000 calls made to 911;
- In 2013, they responded to 33,328 calls;
- In 2017, 48,000 calls were made – 5,000 of the 48,000 calls were made by 225 people;
- In 2017, a new truck and crew were added to accommodate the increasing number of calls. Cost was $500,000.
The KHP Care Management Team partners with providers to offer health coaching and social work support to select contracted populations. Call the KHP clinical service line at 1.877.543.5768 if you have patients needing social work support and learn if they are part of our contracted population.