MIH-CP teams can reduce 30-day readmissions for patients with conditions like stroke and heart failure by taking a few key steps. These include visiting them at home, conducting an environmental assessment, recognizing early signs of decompensation, reconciling medications, coordinating care with their primary care physician, and providing professional guidance on the patient’s health plan.
By taking these actions, hospitals will see fewer readmissions, better overall patient health, and reduced insurance penalties.
How Do MIH-CP Post-Discharge Visits Reduce 30-Day Heart Failure Readmissions?
MIH-CP post-discharge visits reduce 30-day heart failure readmissions by putting a community paramedic in the home within days of discharge to recognize early signs of decompensation, reconcile medications, coordinate with the primary care physician, assess and alter the home environment, and give the health plan professional guidance on the patient’s recovery. The weeks after discharge are the coin flip hospitals cannot control, and the visit is how they win it.
Key Takeaways
- Hospitals can do everything right and still lose the patient to a readmission after discharge.
- Early recognition of decompensation is the highest-value skill on the visit.
- Medication reconciliation catches the errors that send heart failure patients back.
- Coordination with the primary care physician turns one visit into a plan.
How Do MIH-CP Teams Reduce 30-Day Readmissions for Heart Failure Patients?
Reducing hospital readmissions (particularly within the first 30 days) is at the very heart of healthcare’s mission to provide long-term help for individuals with illness and disease. For this reason, more and more health systems are turning to MIH-CP for a solution.
Let’s face it, once that patient leaves the hospital, most areas can do little more than make a phone call to follow up. But this is changing. Thanks to the advanced training and capabilities of community paramedics, post-discharge visits have become more than just a check-in. Now, they’re a full-scale healthcare evaluation.
How MIH-CP post-discharge visits reduce 30-day hospital readmissions:
- Early Recognition of Complications
- Medication Reconciliation
- Coordination with the Primary Care Physician
- Environmental assessment and alterations
- Professional Guidance for Health Plans Post-Discharge
That’s just the start of the story. Let’s walk through it in more detail.
How Does Early Recognition of Complications Reduce Readmissions?
When someone goes home after being in the hospital, it doesn’t mean they are free and clear of all potential risks. As we all know, there is no such thing as zero risk. When it comes to reducing 30-day hospital readmission numbers, there’s a major variable: patient compliance.
Think of this like an athlete training in the off-season. During the season, the personal trainers and coaching staff can constantly monitor the athlete to ensure they meet expected performance benchmarks; however, during the off-season, it’s up to the individual athlete to adhere to their personal training routine. If they do, they’ll likely stay in shape.
If they don’t, they could have a lot of difficulty (and even an increased risk of injury) when the season comes back around.
Similarly, when a patient is in the hospital, physicians and nurses monitor their condition. This means they are monitoring every aspect of patient health: how much they’re moving, what they’re eating and drinking, and, of course, what medications they’re taking.
When community paramedics visit patients after they’ve been discharged, they’re trying to augment the care the patient received in the hospital. During these visits, the MIH-CP team will conduct a patient interview, listen to any concerns, answer questions, and double-check that the physician’s discharge instructions are being followed.
But the team doesn’t stop there. They also take action and complete a physician examination. This is where the patient’s vital signs are evaluated. If there’s a problem, the MIH team can contact the patient’s physician and discuss any potential adjustments.
For example, if someone has a spike in blood pressure, this could exacerbate chronic diseases (such as congestive heart failure). In this instance, the paramedic will ensure that the patient is complying with their medications. If they are and there’s still an issue, the paramedic will confer with the physician to determine whether a dose change or a new medication is warranted.
This proactive, preemptive approach can also be compared to regular maintenance on a vehicle or a home. When the community paramedic visits them after hospital discharge, the cycle of “breakdowns” and “fixes” becomes one of steady calibration.
Speaking of calibration, let’s look at something that often spirals out of control: meds.
How Does Medication Reconciliation Reduce Heart Failure Readmissions?
Heart failure patients require very careful pharmaceutical management. The complications that can develop in someone suffering from congestive heart failure (CHF) are not minor. Physicians must be concerned with heart function, fluid balance, kidney function, and more.
All that said, when dealing with a complex disease, it’s important that the treatment be as straightforward as possible. That’s where medication reconciliation comes into play.
Medication reconciliation is the process of reviewing a patient’s medications – everything they’re currently taking or may take at some point – and ensuring they align with their overall health plan.
Polypharmacy is a commonly described issue, particularly in older adults or those with chronic conditions such as heart failure. The term polypharmacy means “many meds,” and in the case of medication management, this typically means too many medications.
Sometimes, this issue occurs because the patient is reluctant to properly dispose of old or outdated medications. Other times, this is the result of a provider overprescribing new meds for a patient without really digging into what they’re already taking.
To reduce 30-day hospital readmissions among heart failure patients, paramedics will review patients’ medications and ensure that their primary care physician (and any specialists) are fully aware of what they’re taking and how often.
The community paramedic can also educate the patient on what meds they should be taking, how to properly refill them, how to avoid dangerous side effects, and whom to call should they have questions.
How MIH-CP Reduces 30-Day Hospital Readmission: Coordination with the Primary Care Physician
Primary care is an important element in transitioning from a hospital stay to home. When a patient goes home after being admitted for heart failure, they will typically schedule follow-up visits with their primary care providers (PCPs). This is great when it works, as the PCP can answer patient questions, double-check meds, and help keep an eye on them as they assimilate to their home.
When does it fail? It fails for two main reasons. First, the patient is unable to travel to a clinic due to physical limitations. Perhaps they are too weak to drive themselves, or they don’t have any friends or family members who can reliably take them.
Second, there are times when the patient lives in a particularly rural area, and it’s difficult for them to access regular, reliable primary care. In these cases, community paramedics can fill a big gap by providing post-discharge visits.
Community paramedics have the advantage of mobility, allowing them to travel directly to the patient’s home to evaluate them. In many cases, they can use video chat (Telehealth) to help the primary care physician directly evaluate the patient in their home.
This method greatly improves the reach of primary care physicians and reduces the burden of travel on patients.
How Do Environmental Assessments Reduce Readmissions?
Another key element in reducing 30-day post-hospital readmissions among heart failure patients is ensuring that their home environment is conducive to healing. When a community paramedic makes a post-discharge home visit, they don’t just look at the patient – they look at their environment.
Mainly, they’re looking to ensure that the patient is safe. This means looking for trip hazards, ensuring there are no mold or structural issues in their home, and checking that everyone who lives with the patient is a help rather than a hindrance. In this way, community paramedics ensure that the patient’s own home isn’t working against them as they try to heal.
Professional Guidance for Health Plans Post-Discharge
Community paramedics act a bit like personal trainers, helping patients stay accountable to their care plans and encouraging them in the right direction when things go off the rails.
In many cases, it’s not the patient’s fault that they have difficulty following their care plan. For example, some visually impaired patients may have difficulty reading their printed care plan reminders. In other cases, they may not be physically able to perform the required tasks related to exercise or diet.
When these instances occur, the community paramedic is there to help and keep the patient connected to the broader healthcare community.
Conclusion: Mobile Integrated Healthcare-Community Paramedicine Can Reduce Hospital Readmissions for Heart Failure
30-day hospital readmissions are an issue for heart failure patients. However, it’s been demonstrated that community paramedics can successfully reduce hospital readmissions and help people lead healthier lives at home.
MIH-CP teams will evaluate the patient and their environment, check vital signs (so they can catch early indicators of a problem), and connect the patient with their primary care physicians. The result? Fewer penalties for health systems and more healthy years for patients.
Contact Julota if you’re curious to see how their software tools can help you better collect and manage data for your MIH-CP team.
