By Dani Perra, Center for Health Care Strategies
Home-based primary care (HBPC) programs support homebound older adults and people with disabilities to receive high-quality care at home. HBPC patients with urgent care needs, however, often require additional supports related to transportation, observation, and transitional care following acute care treatment. While telehealth innovations allow physicians to visit patients virtually, many HBPC patients have difficulties using the technology.
While HBPC programs have been expanding across the country, many programs are experiencing rising demand and have limited staffing to meet the needs of geographically spread-out patients. The Cleveland Clinic has a longstanding HBPC program. Recognizing its growing geriatric population, Cleveland Clinic created a Paramedic Telehealth Program to provide urgent and transitional care for HBPC program patients.
Today, care teams within Cleveland Clinic’s HBPC program — serving roughly 2,100 homebound older adults averaging 84-years-old — include primary care physicians, nurse practitioners, virtual physicians, and community paramedics. Community paramedicine supports were integrated into the program beginning in 2017. The community paramedics are mid-career professionals, primarily with experience in municipal and private emergency medical services. Community paramedics provide a same-day response for urgent care needs, in-home treatment, and follow-up visits after hospitalization. Paramedics also facilitate greater access to telehealth and enhance the services delivered as part of a telehealth visit. By connecting community paramedics with physicians through telehealth visits while already in the senior’s home, patients can experience the high-touch aspect of an in-home visit as well as have the benefits of new technologies, allowing physicians to see more patients in a wider radius.
The Paramedicine Telehealth Program is a key part of Cleveland Clinic’s strategy to care for homebound older adults. While initially, paramedics supported assessments and access to technology during telehealth visits, over time the program has dramatically increased the role and scope of this position. Now, at the beginning of the appointment, the paramedic uses handheld lab devices and blood analysis machines to get lab work completed, conducts patient assessments, and leads the hands-on part of the exam, before connecting electronically with the physician to conduct a virtual visit, informed by the information gathered by the paramedic. Program leaders noted that accessing telemedicine on their own is “a non-starter” for homebound older adults with high acuity, but this hybrid model supports greater access to telehealth.
Community paramedics in the Cleveland Clinic’s HBPC program receive extensive training. Many community paramedics in the program are board certified in community paramedicine and have studied geriatrics. Cleveland Clinic training for community paramedics focuses on documentation quality, advanced physical exam skills, quality assessment, and judgment and decision-making. Through training and building strong relationships between the community paramedics and the Cleveland Clinic physicians, the paramedics have been able to have more autonomy and respect in the care that happens during their in-home visits. Judy Welsh, MD, Cleveland Clinic Medical Director for Community Care Medicine, described how when a community paramedic does a home visit and tells a physician that “a patient needs hospital care, durable medical equipment, or a change in their medication regimen — I trust their judgment.”
The Cleveland Clinic’s Paramedicine Telehealth program has grown since its inception as the participating community paramedics have strengthened their skills and knowledge base, especially within acute care settings. Paramedics now serve four programs in addition to the HBPC program for older adults. For example, paramedics conduct in-home blood draws for pediatric patients after bone marrow transplants and will soon provide in-home hearing tests for homebound people who require hearing aids. Program leaders attest to the culture of community paramedics — to adapt to new environments and figure out innovative solutions — as a key value.
While patients served by this program are typically very vulnerable and sick, program leaders shared noted that the community paramedicine program has reduced mortality and readmission rates. Sean Lyons, Cleveland Clinic’s Community Paramedic Supervisor, shared an example of a patient story illustrating the program’s value. An 87-year-old patient living at home developed an acute kidney injury, which usually would have led to hospitalization. When the patient refused hospital care due to the COVID-19 pandemic, however, the HBPC team worked together to provide acute care at home. The paramedic collaborated with the physician to run labs and start the patient on intravenous fluids, and then a nurse practitioner and community paramedic partnered to care for this patient until her issues were resolved. The dedicated seven-day-a-week care team was able to meet this patient’s wishes and avert what would have likely been a lengthy hospitalization and decompensation if this patient had not received any care in the home. After this treatment, the patient declared that she was feeling “so good she could do the twist” and did a little twist in her chair.
This is just one example of how HBPC supplemented by community paramedicine can address the needs of homebound older adults in the home rather than what could have been a lengthy hospitalization with complex care. The patient was able to achieve her goals of staying in her home and the care was more effective and efficient due to collaboration across the integrated care team.
Cleveland Clinic Paramedic Telehealth Program leaders reflected on lessons that may support other health care stakeholders interested in integrating a community paramedicine program into a HBPC program:
- Build the right team and invest in staff. Leaders described community paramedics at Cleveland Clinic as lifelong learners who are interested in developing a skill set across acute and chronic care. Paramedics also share peer feedback and lead quality improvement projects. It is important to hire the right individuals who share motivation to work in this environment, which is very different than most other emergency medical services environments. Leaders provide consistent ongoing training on topics such as documentation and specialty equipment and maintain rigorous quality assurance procedures.
- Leadership support helps to assure successful program launch and sustainability. When this program was first launched, home visits from a community paramedic could not be reimbursed. Now, with expanded coverage for telehealth during the COVID-19 pandemic, Cleveland Clinic can charge for a physician visit when a community paramedic and physician deliver a service together. As there are still significant challenges to obtaining the required revenue for these programs, programs must have leadership that understand how paramedics can help a health care organization better address patient needs in their homes. The Paramedicine Telehealth program began with an internal grant to support training and infrastructure, such as blood analytics machine. Program leaders noted the importance of conducting internal research on participant outcomes to demonstrate the value of the program to their system leaders.
Thank you to the following Cleveland Clinic staff for their help informing this blog post: Judy Welsh, MD, Medical Director for Community Care Medicine; and Sean Lyons, Community Paramedic Supervisor for the Cleveland Clinic Paramedic Telehealth Program.