Community Paramedicine Models for Post-Discharge Follow-Up Care

The first few weeks after being discharged from the hospital can be difficult for many patients as they transition back home. Hospital readmissions due to complications or adverse drug events can hamper patients' recovery and are costly to the healthcare system.

Research has found that early follow-up is a key intervention to reduce avoidable readmissions and help patients get comfortable with their new health routines. As a result, protocols generally call for an initial contact with the patient no more than 72 hours after their discharge.

Local home health agencies are often the traditional community providers for post-discharge follow-up. However, if they are not able to see a patient within their first few days at home, community paramedics can fill the gap by conducting early visits for patients who are waiting for a home health appointment or may be ineligible for home health services because of their insurance status.

A community paramedic's responsibilities during a post-discharge visit may include reviewing next steps and discharge instructions, discussing and planning for lifestyle changes, educating patients on how to manage new medications, and ensuring people have appropriate temporary or permanent physical accommodations and medical equipment to support their recovery.

Evaluation data suggest that community paramedicine programs have a significant impact on readmission rates. A study in New Jersey found heart failure patients without a visit from the mobile integrated health team were 30.3% likely to be readmitted within 30 days. Another pilot program in urban Oregon found a readmission rate of 6.3% for program participants, compared to 23.5% of patients who did not participate.

Examples of Post-Discharge Follow-Up Care by Rural Community Paramedicine Programs

Abbeville County's Community Paramedic Program served rural western South Carolina and was designed with a goal to reduce hospital readmissions. The program received referrals from providers whose patients are hospitalized and conducted home visits within 72 hours of discharge. At each visit, the paramedic also worked with the patient's family or other caregivers to discuss how best to manage their care. In a 2015 evaluation, the program had reduced 30-day readmission rates by 41.2%.
In West Virginia, the Kanawha County Ambulance Community Paramedicine Program was developed to reduce costs from hospital readmissions and frequent emergency room visits. In its first year of operation, the program achieved a decrease in readmissions and an increase in Patient Activation Measure (PAM) scores, which indicate people who participated in the program are more confident in their ability to manage their health.

Considerations for Implementation

For communities just beginning to implement a community paramedicine program, post-discharge follow-up can be a good starting point. This model offers opportunities to build partnerships with local hospitals and home health agencies, which can later be expanded to accommodate new lines of work. People living in rural communities also often have a higher burden of chronic disease and may benefit from post-discharge follow-up, including for heart failure, chronic obstructive pulmonary disease (COPD), pneumonia, and diabetes.

A focus on reducing readmissions may be a particularly good fit for emergency medical services (EMS) operated by hospitals that could be financially penalized for higher-than-average readmission rates. The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that cuts reimbursement for some hospitals based on their rates of avoidable readmission for patients with six conditions including heart failure, coronary artery bypass graft surgery, and hip and knee replacements. Therefore, implementing a community paramedicine program may be a good investment for the hospital system. Critical Access Hospitals are exempt from these penalties but may be incentivized to reduce readmissions through the Medicare Beneficiary Quality Improvement Project.

Program Clearinghouse Examples

Resources to Learn More

Community Paramedic Pilot Program: Congestive Heart Failure
Video/Multimedia
Presents an interview with a community paramedic from the Glendale Fire Department discussing the elements of its program, which targets post-discharge patients with congestive heart failure. Paramedics conduct vital signs screening and provide education on disease management. The program was a pilot project of the California Emergency Medical Services Authority.
Organization(s): Glendale Fire Department (California)
Date: 2/2016

Congestive Heart Failure Readmission Prevention Program
Document
Describes a readmission prevention program developed specifically to support patients with congestive heart failure. Discusses the enrollment process, core program components, coordinating the patient care with other providers, and results of the program evaluation.
Organization(s): MedStar Mobile Healthcare

Update of Evaluation of California's Community Paramedicine Pilot Program
Document
Summarizes the findings from the California Community Paramedicine Pilot Program with a focus on post-discharge, frequent users of emergency medical services, direct therapy, transportation to alternate destinations, and treating hospice patients. Includes information about how each intervention was structured, each site's readmission rates before and after the program, services provided by the paramedics, and the estimated potential savings to payers.
Author(s): Coffman, J., Blash, L., & Amah, G.
Organization(s): Healthforce Center, University of California, San Francisco
Date: 2/2019