Rockdale Medical Center in suburban Atlanta teamed up with community partners on an initiative that has reduced readmissions and ED visits by high-risk, medically underserved patients.

  • The program’s medical social worker/patient navigator contacts referred patients — preferably in person while they are in the hospital — and assesses their medical and social needs and creates patient plans.
  • A specially trained paramedic visits patients at home, checks on their health, educates them on their conditions and how to manage them, and assesses their living conditions and needs.
  • The social worker and paramedic work together to fill in the gaps in care and connect patients with community agencies that can meet their needs.

A collaboration between Rockdale Medical Center in suburban Atlanta and community partners has reduced readmissions, ED visits, and calls for emergency services among high-risk, medically underserved patients with poorly controlled chronic conditions.

The Healthy@Home Community Paramedic Program, which started in January 2015, sends a specially trained paramedic from National EMS to provide health checks and education to patients at home. The paramedic works closely with a social work case manager at the 138-bed acute care hospital who coordinates community resources for the patients. The program is funded by Health TRUST Rockdale, the grant-making division of the Hospital Authority of Rockdale County (HARC). The trust was created using proceeds from the 2009 sale of Rockdale Medical Center, formerly a public hospital, to private company LifePoint, Inc. The Rockdale Coalition for Children and Families administers the fund.

In the first 18 months of operation, the Community Paramedic Program provided almost 1,000 home visits to more than 100 chronically ill Rockdale County residents, according to Jennifer Phillips, MSW, case manager at Rockdale Medical Center, and medical social worker/patient navigator for the Healthy@Home program.

The hospital experienced a 2% housewide drop in readmissions in 2015, Phillips says. Patients in the program have experienced a 25% reduction in avoidable readmissions, a 32% decline in ED visits, and a 45% drop in non-emergent 911 calls.

The Georgia Hospital Association awarded its 2016 Community Leadership Award to the Community Paramedic Program and Rockdale Medical Center, and recognized Phillips as a “Hospital Hero” for her work in the program.

The hospital already had a targeted readmission reduction program when Benny Atkins, chief operating officer of National EMS, the county’s contracted emergency medical services provider, proposed his organization and the hospital collaborate on a program to provide home visits by paramedics to at-risk patients.

“We felt this was a natural fit with what we were trying to do,” Phillips says.

The program targets patients with poorly controlled chronic medical conditions, including those with no insurance, those who are underinsured, and patients without a primary care provider. It includes patients who have been to the ED more than five times in 18 months, those who have been readmitted to the hospital within 30 days of discharge, people with chronic conditions including diabetes, heart failure, pulmonary diseases, or recurrent wounds, elderly individuals, and those identified by a physician as being high risk.

When patients are referred to the program, Phillips meets with them in the hospital whenever possible. Otherwise, she contacts them by telephone. “I always try to meet them face to face to discuss the program and get their permission for the paramedic visits,” she says. She completes a detailed clinical and psychosocial assessment that identifies the patients’ needs and barriers to following their treatment plan.

Phillips uses the information from the assessment to create a rough plan for the patient and shares it with the paramedic team. She also enters each patient’s medical information into an online charting system that uses cloud technology. This way, the hospital and the paramedics can review the chart and have an idea about the patient’s condition before going to the house.

The program takes a three-pronged approach to improving the health of the Rockdale County community, Phillips says. “Through the assessment and the home visits, we determine what their needs are. Through the social services network in the area and our partnership with the Rockdale Coalition, we can meet their needs. We can pay for transportation, patient copays, and office visits, as well as helping patients access community services,” she says.

Teaching patients to become self-supportive is the third component of the program. “We don’t provide lifetime support. Our goal is to get them on their feet, establish them with a primary care provider, and teach them to take responsibility for their own health,” she says.

The program helps patients get established with a primary care provider and any specialists they may need to get their problem under control. The program connects patients with food banks, utility assistance, and housing assistance programs, and helps them apply for Medicaid if they are eligible.

Jeanann Briscoe, NREMT-P, an experienced paramedic who came out of retirement to staff the program, visits the patients in a specially equipped van dedicated to the program. Other paramedics assist her when necessary.

When Briscoe goes into a patient’s home, she assesses the patient’s living condition and contacts Phillips if there are social issues that weren’t uncovered during the assessment. Depending on the needs, Phillips coordinates the services herself or guides Briscoe on what community resources can provide assistance.

“Our goal is to teach the patients how to access the services themselves,” she says.

During each visit, Briscoe takes the patient’s vital signs, conducts a health check, and looks for signs of an acute problem. “My goal is to anticipate what care the patients need before they end up in the emergency department or the hospital,” she says. She may contact Phillips, who will arrange an immediate visit with a primary care provider or specialist and, if needed, contact the Rockdale Coalition about any copay that is needed.

She educates the patients about their diseases and their medication, and coaches them on nutrition, exercise, smoking cessation, and other lifestyle changes that can improve their health. “We teach patients the signs and symptoms that indicate they should call their doctor. Our goal is have them calling their primary care provider on their own within the first month,” she says.

During the home visits, Briscoe establishes a rapport with patients and discovers needs that aren’t immediately apparent. For instance, after several visits, one man admitted he didn’t understand the information he’d gotten in the hospital because he couldn’t read well. Briscoe went over the information with him and alerted his primary care provider and insurance company to give him verbal instructions.

“Health literacy is another huge barrier. Medical terms are hard for people to understand, so I go through the information and break it down,” Briscoe says.

Briscoe visits once a week for the first month, then gradually tapers off the visit until the patients feel confident to care for themselves. Phillips is always available by telephone after people have completed the program.

The hospital has been working with Facie Goodman, resource coordinator of the Rockdale Coalition for Children and Families, to build a network of social resources for county residents, Phillips says. Among the participants are a family-owned pharmacy that works with the uninsured, a durable equipment company that gives the program a discounted rate, a local physician office that takes patients in the program, and the Mercy Heart Free Clinic.