An innovative program developed by NewYork-Presbyterian and Weill Cornell Medicine that combines physician telehealth with home health care administered by paramedics helps reduce hospital readmissions for patients with heart failure and other chronic conditions, according to recently published research in NEJM Catalyst.
The Community Tele-Paramedicine (CTP) program started in 2018 as a small pilot to help manage patients with advanced heart failure in medically underserved populations. After a year, the program was expanded to include any hospitalized patient who had two or more hospitalizations in the past year, as well as any NewYork-Presbyterian and Weill Cornell Medicine patient struggling to manage two or more chronic diseases.
“Many of these patients are severely impacted by adverse social determinants of health that make it difficult to access needed care,” says Brock Daniels, M.D., MPH, director of the Community Tele-Paramedicine Program and an emergency medicine physician at NewYork-Presbyterian and Weill Cornell Medicine, who is also the lead author on the paper. “It was very clear that there were things we could do to prevent emergency department visits and avoidable hospital admissions.”
The study looked at patients enrolled in the New York Quality Care ACO and found the 30-day readmission rate was 5% among patients in the program, compared with 12% for control patients, and rates continued to be lower for CTP patients at 60 and 90 days.
“The Community Tele-Paramedicine program offers our patients the best of both worlds — access to engaged, in-person care where the patient is most comfortable, with the added value of an assessment by an emergency medicine physician through a virtual visit,” says Rahul Sharma, M.D., MBA, emergency physician-in-chief at New York Presbyterian and Weill Cornell Medicine and executive director of the Center for Virtual Care at Weill Cornell Medicine, who was also a co-author of the study. “This is the closest thing to the physician home visit of the 1950s.”
A Hybrid Care Model
Dr. Daniels, an assistant professor of clinical emergency medicine at Weill Cornell Medicine, oversees operations, training, and quality assurance for the CTP team, which is supported by the Center for Virtual Care. Additional staff include two nurse case managers who coordinate care; two full-time community paramedics and eight rotating paramedics; and a group of emergency medicine physicians who perform telemedicine.
This is, in many ways, geared to be a transition care program for when the inpatient teams feel that the patient might have a difficult time transitioning back to home successfully.
— Dr. Brock Daniels
When a patient is referred to the CTP program, an initial appointment is set for the paramedics to visit — and they bring all the technology needed, including a Wi-Fi hotspot and tablet. The paramedics do a safety assessment of the home, perform a complete physical exam, administer some medications, do cardiac monitoring, and perform point-of-care blood tests.
“These are things that you can’t do in a normal telehealth visit and that really provide that higher level of care to sicker patients,” Dr. Daniels says. “This is, in many ways, geared to be a transition care program for when the inpatient teams feel that the patient might have a difficult time transitioning back to home successfully.”
CTP program patient Juanita Baez has her vitals checked during a home visit with emergency medical technician Derrick Bheer. All the technology required to conduct a visit is brought directly into patients’ homes.
If the patient has been recently discharged from the hospital, the paramedics review the discharge instructions and perform a medication reconciliation. “We find, not infrequently, that people will just have a giant bag full of medicines,” he adds. “Having the medics there to go through them one by one with the electronic health record in front of them has made one of the biggest differences. If there’s a discrepancy, we also have a physician on telemedicine whom they can talk to.”
The emergency physicians will also assess whether patients can be safely treated at home or need to return to the hospital. “This comprehensive view of the patient's world allows us to address the health issues that are already known and also provide preventive care for those that may arise in the home environment,” says Dr. Sharma, who is the chair of the Department of Emergency Medicine and the Barbara and Stephen Friedman Professor of Emergency Medicine at Weill Cornell Medicine. “It allows us to employ rapid response care when and if it's needed.”
Being in their home with them not only improves care, but it also allows us to build better relationships with the patients. They can be assured that they are receiving focused, high-quality care delivered in a dignified way.
— Dr. Rahul Sharma
Improving Access
Not only did the intensive hybrid approach of CTP produce fewer emergency department visits and lower hospital readmissions, the research showed it also helped make quality health care more accessible in underserved communities, one of the main goals of the program.
CTP program patient Loretta Copeland speaks to an emergency medicine physician for her telehealth visit.
Compared with populations served by traditional telehealth services at NewYork-Presbyterian and Weill Cornell Medicine, CTP patients were more likely to live in communities with unmet medical needs, more chronic illness, and adverse social determinants of health, says Dr. Daniels. And in an analysis of Medicare claims data, he and his team found that the average cost of care for patients in the program was 18% lower than for control patients.
“Even with the rise in telehealth, communities impacted by adverse social determinants of health are less likely to know how to effectively use it. They also tend to distrust health care institutions more,” says Dr. Daniels. “A key finding of our research is that an intensive home-visit program like CTP helps patient become more comfortable with Telehealth and increases engagement with the health system.”
“Being in their home with them not only improves care, but it also allows us to build better relationships with the patients,” adds Dr. Sharma.
