Patte Creel has taken care of her mother, Lorena Merritt, in their Katy home for three and a half years, since her mother had a stroke and developed cardiac issues, she said. But caring for her mother has not been easy, Creel said.
Merritt has a heart that only functions at 20 percent capacity, which makes her susceptible to falls from light-headedness and other heart failure symptoms, Creel said. Caring for Merritt is expensive, stressful and reduces Creel’s ability to spend time away from home because of her mother’s tendency to fall or pass out due to poor circulation, Creel said.
“We’ve called [emergency medical services]10, 12 times maybe, because she’ll pass out; she’ll fall; she’ll hit her head, whatever it is,” Creel said.
Merritt was admitted to the hospital six times in 2018, Creel said.
Nationwide, about 15.3 percent of patients returned to hospitals within 30 days of discharge from 2014-17, according to the Centers for Medicare & Medicaid Services. Katy-area hospitals saw about 14.7-24.39 percent readmission from 2013-17, depending on the illness, CMS reports indicated.
High readmission rates for hospitals translate into fines for hospitals, increased costs for patients and workloads for paramedics, experts said.
Harris County Emergency Services District 48 is partnering with Houston Methodist West on a community paramedic program, said ESD 48 paramedic Joe Casciotti, who runs the program. A bilateral agreement was signed in January, said Denise McCall, Houston Methodist West emergency services director.
The program’s goal is reducing the risk of patients returning within 30 days of discharge through education, coordinating communication with physicians and referring patients to resources such as nonprofits, doctors and home care providers, Casciotti said.
Merritt was one of the first patients to receive community paramedic services in December, Casciotti said. Creel said she has less stress since the first visit.
“I think being able to talk to someone that understands and can truly tell me they see [my mother’s condition]and can view the situation objectively is good,” Creel said.
A readmittance problem
Houston Methodist West’s 2018 cardiac patient readmission rate was about 16 percent, McCall said. Data from CMS indicate that is better than about 21 percent in 2016 and the national rate of 22 percent.
Although its numbers are improving, Houston Methodist West would like to reduce its rate further to benefit patients, reduce costs and improve emergency room efficiency, McCall said.
“Readmissions are costly for everybody, regardless of whatever hospital system you are a part of,” McCall said.
The Affordable Care Act penalizes hospitals for high readmission rates. In 2017, Houston Methodist West paid about $48,000 in penalties, according to CMS. Memorial Hermann Katy saw about $50,000 in penalties that same year. Nearby West Houston Medical Center paid more than $178,000 in CMS penalties in 2017. Hospitals cannot pass these costs to patients, McCall said.
Patients may pay $3,000 per ambulance trip, Casciotti said. Hospital costs may run tens of thousands of dollars, McCall said.
Federal programs partially reimburse hospitals when patients cannot pay their bills passing costs on to tax payers, McCall said.
Preventable calls are a problem for EMS agencies, and community paramedics improve efficiency by preventing emergencies, said Elizabeth DeLeon, community paramedic coordinator for Fort Bend County.
DeLeon said before Fort Bend County EMS began community paramedicine in partnership with OakBend Medical Center in 2014, some patients called 911 about 40 times per year.
“They did not know their disease process so would call out of fear,” DeLeon said.
About 67 percent of ESD 48’s EMS calls in 2018 were fall-related, Casciotti said. Most of those calls involve patients with cardiac or respiratory-related falls, he said. The pilot for ESD 48’s program is focused on cardiac patients, he said.
Foundation of care
The community paramedic program educates patients about their health care by providing a foundation of community care providers to help patients adhere to aftercare plans, Casciotti said.
The program seeks to emulate successful programs in Fort Bend County and the Dallas area, Casciotti said.
High-risk patients are identified by medical staff and enrolled in the program voluntarily, he said. Within 48 hours of discharge, a paramedic visits the patient to review and coordinate aftercare. This practice can prevent unnecessary emergencies, which lead to hospital admissions about 60 percent of the time, he said.
Community paramedic visits connect patients with resources such as transportation, food or legal assistance their absence hinders care, Casciotti said.
Establishing the program has minimal costs, Casciotti said. Fuel and supplies are expected to cost the department less than $40,000 for the first year, a department spokesman said. That cost does not include staffing, Casciotti said.
Fort Bend County EMS has spent about $1.4 million on the program over the last five years, said Fort Bend County EMS Chief, Graig Temple. That includes startup costs, supplies and employee salaries, he said.
In Dallas, community paramedicine helped prevent nearly 50 percent of patients—who were expected to return to the hospital within 30 days of discharge—from being readmitted, according to MedStar Mobile Healthcare, which operates the program.
Since Casciotti first visited with Creel and Merritt in mid-December, Merritt has not returned to the hospital, Creel said. She is certain that, without Casciotti’s advice and assistance, Merritt would have been hospitalized at least once since then.
Casciotti said his goal is reducing Methodist West’s approximately 16 percent readmission rate for cardiac conditions to 12 percent during the program’s first year and reducing nonemergency calls by 20 to 30 percent.
If successful, the community paramedic program may expand to hospitals such as Memorial Hermann Katy and grow to include patients with additional medical conditions, he said.
Casciotti said he is looking for money to fund the program’s growth, such as a grants from hospitals, nonprofits and Medicare. Fort Bend County EMS received more than $250,000 in Medicare grants to fund the program in 2016 and 2017.
Fort Bend County’s program offers an example of the conditions ESD 48 may consider when expanding its program, DeLeon said. The Fort Bend community paramedicine program includes diabetes and joint replacement patients, she said.
Community paramedicine has given Creel peace of mind and hope for the future, Creel said.
“I think [my mom’s]quality of life will get better,” Creel said. “I think right now, I feel more comfortable saying—‘OK. You can do this. You can do that.’—I have direction.”