After Five and on Weekends: A Home Health and Community Paramedicine Partnership to Treat Urgent Problems at Home
Student Name
Master of Science in Nursing Program, Aspen University
N684: Case Management and Home Health Nursing
Instructor Name
Month Day, Year
After Five and on Weekends: A Home Health and Community Paramedicine Partnership to Treat Urgent Problems at Home
Home health nurses visit patients on scheduled days, usually during weekday business hours. Problems do not keep to that schedule. When a patient with heart failure becomes more breathless on a Saturday evening, or a catheter becomes blocked at night, the options are often a phone call to an on-call nurse who cannot see the patient, or a 911 call that ends in an emergency department visit and frequently a hospital admission. This paper proposes an innovation to fill that gap: a partnership between a composite home health agency and the county's emergency medical services agency in which specially trained community paramedics evaluate and treat home health patients at home during evenings and weekends, with physician guidance and a direct line to the patient's home health nurse.
The Problem
The composite agency's data show that 41% of its patients' emergency department visits over the past year began between 5 p.m. and 8 a.m. or on weekends, and that about half of those visits ended in admission. Chart reviews suggest that many involved problems that could have been managed at home with assessment and a change in treatment: fluid overload that responded to additional diuretic, urinary catheter problems, mild dehydration, and falls without injury in patients who could not get up. Each visit also exposed frail patients to long waits and the risks of hospitalization.
The Evidence
Community paramedicine and mobile integrated health care use emergency medical services personnel, often with additional training in chronic disease management and communication, to fill gaps in local health care. A review of the model found that program data suggested it may prevent heart failure readmissions and reduce emergency transports and emergency department visits, while noting that few rigorous studies of efficacy, safety and cost had been done (Choi et al., 2016). Evidence has since grown. In a cluster randomized trial in social housing for older adults, weekly paramedic-led health sessions in the intervention buildings were associated with fewer ambulance calls than in control buildings, along with improvements in blood pressure and quality of life (Agarwal et al., 2018).
The model most similar to this proposal is a program in which community paramedics, trained to evaluate and treat acute illness in homes with telemedicine-enhanced physician guidance, responded to urgent needs among 1,602 older adults with advanced illness. Of 664 paramedic responses, only 22% required transport to the emergency department; 78% were evaluated and treated at home. Patients the paramedics did transport were more often admitted than those brought by traditional ambulance, suggesting that the paramedics were selecting appropriately, and all survey respondents rated the program highly (Abrashkin et al., 2016). The study was observational, so it cannot show that outcomes were better than they would otherwise have been, but it demonstrates feasibility with a similar population.
The Partnership Model
Under the proposal, home health patients at high risk of emergency visits, identified at admission, are enrolled with their consent. When an enrolled patient or caregiver calls the agency's after-hours line, the on-call nurse triages the call. If an in-person assessment is needed but the situation is not an emergency, the nurse requests a community paramedic, who arrives within about an hour with the patient's current medication list and care plan. The paramedic assesses the patient, connects by video with an on-call physician from the agency's medical partner, and can provide treatments within agreed protocols, such as an additional diuretic dose, intravenous fluids, catheter replacement, point-of-care tests and help after a fall. If the patient needs the emergency department, the paramedic transports them. Within 12 hours, the paramedic's documentation reaches the patient's home health nurse, who visits the next business day.
Training builds on paramedics' existing skills. Community paramedics in the program complete additional training in chronic disease management, geriatric assessment, medication reconciliation and communication with patients and families, and spend shifts with home health nurses to learn how the agency works and what its care plans contain. Home health nurses, in turn, ride with paramedics to understand their assessment approach, which builds mutual trust.
Roles and Governance
Each partner has a defined role. The home health agency identifies eligible patients, provides care plans and medication lists, triages calls and follows up after every paramedic visit. The emergency medical services agency trains and staffs the community paramedics, maintains their competencies and supplies the vehicles and equipment. The medical partner provides physician oversight and approves the treatment protocols. A joint steering group, including a home health nurse leader, the emergency services medical director, a physician and a patient representative, reviews every transport and every adverse event monthly. A data-sharing agreement governs access to patient information, and the state's emergency services regulations are reviewed to confirm that the planned treatments fall within the community paramedic scope.
Measures and Funding
The pilot will run for 12 months with about 150 enrolled patients. Primary measures are the proportion of paramedic responses resulting in treatment at home, emergency department visits and hospital admissions per 100 patient-months compared with a matched group from the prior year, and 72-hour return visits after treatment at home as a safety measure. Secondary measures include patient and caregiver experience, time from call to paramedic arrival and cost per response. Funding in the pilot year will come from the health system's accountable care organization, which bears the cost of avoidable admissions, with the goal of a shared-savings arrangement if results are favorable.
Conclusion
The gap between scheduled home health visits and the times when patients become ill leads to emergency visits and admissions that are sometimes avoidable. A partnership with community paramedics, who can assess and treat at home with physician guidance and hand back to the home health nurse the next day, is a practical innovation with growing evidence, including a program in which most responses ended with treatment at home. Clear protocols, defined roles, safety review and careful measurement will show whether it improves care for the agency's patients.
References
Abrashkin, K. A., Washko, J., Zhang, J., Poku, A., Kim, H., & Smith, K. L. (2016). Providing acute care at home: Community paramedics enhance an advanced illness management program. Preliminary data. Journal of the American Geriatrics Society, 64(12), 2572-2576. https://doi.org/10.1111/jgs.14484
Agarwal, G., Angeles, R., Pirrie, M., McLeod, B., Marzanek, F., Parascandalo, J., & Thabane, L. (2018). Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: A cluster randomized trial. CMAJ, 190(21), E638-E647. https://doi.org/10.1503/cmaj.170740
Choi, B. Y., Blumberg, C., & Williams, K. (2016). Mobile integrated health care and community paramedicine: An emerging emergency medical services concept. Annals of Emergency Medicine, 67(3), 361-366. https://doi.org/10.1016/j.annemergmed.2015.06.005
How this N 684 Module 8 example is structured
Aspen does not publish N684 module prompts, so check your classroom for the exact instructions. This example defines the gap with agency data, reviews evidence with its limits, describes the partnership's care pathway, assigns roles and governance, and sets measures and funding for a pilot.
N684 Module 8 questions, answered
What does N684 Module 8 usually ask for?
Aspen's N684 description includes innovation in case management and home health care, so a paper proposing an innovative care delivery model is a typical final assignment. Check your classroom for the prompt.
What is community paramedicine?
A model in which emergency medical services personnel, often with extra training, provide care outside emergency response, such as home assessments, chronic disease follow-up and treatment at home under physician guidance.
How should an innovation proposal be evaluated?
With measures of the intended benefit, such as avoided emergency visits, a safety measure such as return visits, patient experience and cost, compared with a reasonable baseline.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.