HealthAffairs Source Article | Comments Courtesy of Matt Zavadsky
Nice article and research! Congratulations to the ThedaCare Team!
Another good example of gaps being filled through the innovative use of Community Paramedics!
Deploying Community Paramedics To Address Medication Complexity At Home
Caitlin Thomas-Henkel, Sandi Groenewold
JANUARY 30, 2019
Complicated drug regimens are often a challenge for people with complex health and social needs, including individuals with physical and behavioral health comorbidities, seniors, and those dually eligible for Medicare and Medicaid. It is not uncommon for people with complex needs to take 20 or more medications daily, typically prescribed by multiple providers, and often with complicated dosing schedules and confusing instructions.
Outside of clinic walls, people are left to interpret and develop their own medication schedules with little to no ongoing support, which is where things get tricky, if not downright dangerous. In the US, 119,000 deaths are attributed to medication errors annually. The more complicated the medication regimen, the higher the probability of a patient not following it correctly, increasing the likelihood for largely preventable adverse drug events to occur. Additionally, each medication added to a drug regimen is linked to a 10 percent increase for adverse drug events, which can lead to increased hospitalizations, exacerbations of disease, and even premature death—not to mention the impact on patients’ quality of life and adverse drug event expenses, which are estimated to cost up to $180 billion annually.
The difficulties of managing complicated medication regimens are compounded among people with low incomes and multiple chronic conditions who face social challenges, such as low health literacy and lack of transportation and access to nutritious food. Managing medication complexity requires that patients have a firm grasp of the purpose of their medications and how to use them. It also requires that they are able to follow a daily and consistent schedule over time, which includes the ability to adapt to changes within the schedule as necessary. This is no small task for someone already burdened with multiple chronic conditions and challenging social issues. Addressing medication complexity requires a holistic approach, which should include deploying providers, such as community paramedics, in new or expanded roles.
In-Home Opportunities For Addressing Medication Complexity
Unlike a traditional paramedic, whose goal is to quickly triage and process an emergency situation, a community paramedic builds a therapeutic rapport with patients to understand what is going on “below the surface.”
Community paramedics are able to go where clinicians typically do not—into the patient’s home—where they may discover unexpected barriers and underlying factors that affect health outcomes. Barriers related to medication complexity may include prescription drugs being stored incorrectly, patients taking expired medications or over-the-counter supplements that have not been reported to their provider(s), or patients having difficulties adhering to complicated medication instructions. A community paramedic can investigate these issues firsthand and seek ways to solve them through patient education (such as needing to take food with certain medications, developing reminders for medication schedules, or special packaging), connecting the patient with community resources, or both. This approach is a paradigm shift that differs from the traditional one-way model of medication prescribing and dispensing to a patient-centered approach.
To be effective, community paramedics must first establish a rapport with patients to build their trust. This takes time. Fortunately, community paramedics are not typically constrained by pre-defined visit schedules, which allows them the flexibility to customize their visits and spend additional time with patients as necessary. This results in a deeper understanding of patients’ support systems, individual needs, day-to-day routines, and factors that can influence their overall health.
One promising community paramedicine model that is beginning to show results for individuals with complicated medication routines is ThedaCare’s community paramedicine pilot program in eastern Wisconsin.
ThedaCare Community Paramedicine Pilot
In 2015, ThedaCare and Gold Cross Ambulance Service partnered to develop a community paramedicine pilot that integrates community paramedics into the ambulatory care management team of nurses, primary care physicians, pharmacists, and social workers. Since 2016, community paramedics in the pilot program have visited more than 150 Medicaid, Medicare, and dually eligible members who were at-risk for repeat inpatient stays and emergency department (ED) visits.
Before its focus on medication complexity, ThedaCare initially targeted patients with uncontrolled diabetes, which resulted in significant decreases in HbA1c levels—78 percent of those enrolled had improved readings, as compared to only 44 percent of members in a standard care control group based on age, sex, and similar HbA1c patterns prior to enrollment (Exhibit 1). In addition, ED visits declined by 47 percent in the six months following enrollment as compared to a 9 percent increase in the control group. During the same time, inpatient hospital admissions decreased by 31 percent compared to no change in the control group.
Exhibit 1: Results: Emergency Department Use Patterns, Six-Month Pre- And Post-Enrollment Comparison
Despite these successes, the ThedaCare team identified a troubling pattern among its complex patients—many who were admitted to the hospital were taking multiple medications and having difficulty managing their complicated drug regimens. This was leading to exacerbations of their underlying disease(s). Through funding from the Gordon and Betty Moore Foundation’s Community Management of Medication Complexity Innovation Lab, ThedaCare expanded the paramedicine pilot to address medication complexity. The goal was to identify patients with medication complexity and intervene before they ended up hospitalized.
To do this, ThedaCare developed a medication risk score based on:
- Total number of medications;
- Use of high-risk medications—those that have a high risk of causing patient harm and even death when used incorrectly (such as anti-coagulants, insulin, and antiarrhythmics);
- New, changed, or discontinued medications; and
- A multiplier based on insurer type (commercial health insurance, Medicaid, Medicare, dually eligible, or uninsured).
The process begins when a physician- or nurse-ordered alert appears in the electronic health record (EHR), flagging ThedaCare’s ambulatory care management team to assess the patient’s chart for medication complexity. If the resulting medication risk score is a five or higher, the team then determines the most appropriate course of action for the patient, which may include home visits by the community paramedic or other care team members, phone follow-up, video consults, or some combination of these. EHR data can be accessed during home visits to provide real-time updates on patients, including changes to medication lists.
Since ThedaCare began using the medication risk score in July 2018, the score has triggered more than 150 referrals to the ambulatory care management team, with 49 percent of patients enrolling in the home-visiting program. A majority of the patients triggered had five or more medication changes.
Recently, a 59-year-old patient with multiple health conditions was hospitalized with sepsis due to a jaw abscess. He was also newly diagnosed with diabetes mellitus. Upon hospital discharge, he was referred to the ambulatory care management team because he was on an anticoagulant and multiple new medications, including insulin. A community paramedic began visiting him regularly to monitor his HbA1c levels, as well as his new medication regimen.
After treatment for the infection, the patient underwent dental extractions. Afterwards, while meeting with the patient, the community paramedic learned that the patient had stopped his insulin four days prior. He had assumed that since he was on a liquid and soft foods diet following the dental procedures, he did not need to take his insulin. The community paramedic explained that the patient was still at high risk for recurrent infection, so having good blood sugar control was very important. Three months after he began meeting with the community paramedic, the patient’s HbA1c had decreased from 9.0 to 6.4. The intervention not only prevented a potential health disaster for this patient but increased his understanding of proper use of his medications and improved his overall health.
Spreading The Model
Piggybacking on Minnesota’s successful efforts to certify and reimburse community paramedics, Wisconsin recently passed a bill to create an approval process and certified training program for community paramedics. With this legislative buy-in, the role of community paramedics is strengthened and officially recognized as a needed addition to solving local health care issues, including medication complexity and the myriad problems it creates for patients and providers.
Looking ahead, there are a variety of policy steps that can further spread the adoption of community paramedics and other innovative community-based medication management approaches:
- Deploy health information technology in new ways, such as proactively identifying at-risk patients, for example by using a medication risk score, and establishing robust health information systems critical to enhancing community-based medication services. Other approaches include enabling EHR information exchange among pharmacists and primary care providers to identify changes to a patient’s medication regimen and recent hospitalizations or ED visits. The use of videoconferencing is another way to manage effectively complicated medication regimens, allowing pharmacists to video chat with patients and care team members about medications during home visits.
- Strengthen the capacity of workforce members, including pharmacists and non-traditional workforce members, such as community paramedics, to deliver optimal care in home and community settings. This includes supporting patients in understanding how medications should be taken, looking for potential risk factors in complicated medication regimens, identifying barriers to taking medications, and finding low-cost-pharmaceutical programs.
- Implement outcome-driven quality measures that can potentially serve as a foundation for monitoring progress on medication management interventions. Aligning community-based interventions to specific health outcome measures and tracking these on an ongoing basis are critical steps to improving care.
Although providers are in the nascent stages of developing community-based strategies to address medication complexity, the field can garner valuable lessons from early adopters such as ThedaCare. To drive momentum forward, it will require policy reform efforts and partnerships among health plans, community providers, and payers to increase system capacity to provide these types of community services. As recognition of the importance of addressing medication complexity among our most vulnerable populations increases, community-based innovations in medication management will undoubtedly flourish.