I attended the fourth annual “Building an Evidence-Based MIH-CP Program” seminar presented by Baxter Larmon, Dan Swayze, and Matt Zavadsky at the 2018 EMS Expo Conference. This all-day seminar covers on how to do research that can be published in a peer-reviewed professional journal. What I learned was something entirely different.
This is the latest version of the “do-your-own-research” mission that started when Professor Larmon created the Prehospital Care Research Forum at UCLA in 1992.
Hospital Readmissions within 30 Days
Hospital readmissions are common and expensive, with nearly 20% of Medicare patients being readmitted to a hospital within 30 days of discharge at an overall cost of nearly 20 billion US dollars per year. Because of this high frequency and cost, hospital readmissions within 30 days of discharge are a target for health care cost savings in the Medicare Value Based Purchasing (VBP) program.
The VBP aims to incentivize hospitals and health systems to reduce readmissions through reductions in payments to hospitals with higher than expected readmission rates. Because of the VBP initiative, healthcare organizations are investing considerable resources into efforts to reduce hospital readmission.
LACE index
The modified LACE index is designed to identify patients who are at risk for readmission or death within thirty days of discharge. It is based on four factors:
L – Length of stay during the previous acute care admission within the last 30 days
A – Acuity of admission (Yes or No)
C – Co-morbidities (Charlson comorbidity index score)*
E – Emergency room visits within the last six months
The LACE index goes from 0 to 19. The higher a patient scores on this index, the higher the risk of returning to the hospital. The important markers of the LACE score vary based on the disease. In one study, the median LACE score was 5 for all patients getting discharged.
Readmission rates in some hospitals doubled as the LACE score moved from 10 and 11, suggesting that 11 may be the optimum threshold for distinguishing between patients at a lower or higher risk of readmission. Other studies use a LACE score of 10 as the threshold.
El Morr showed the relationship of the LACE index to hospital admissions in his study. You can see the green line of readmissions steeply climb after the LACE index value is 11:
Validated risk assessment tools such as the LACE index have been developed to identify patients at high risk of hospital readmission so they can be targeted for interventions aimed at reducing the rate of readmission. This is an area a community or mobile integrated health (CP-MIH) paramedic has an opportunity to manage the high-risk patients to avoid a readmission within 30 days.
A great part of this seminar was learning about the experiences from Larmon, Swayze, and Zavadsky. These stories helped the new researcher understand the current experiences in the CP-MIH environment so the new researcher can craft a high-impact study.
The CONNECT Community Paramedic Experience
Dan Swayze runs the most successful community paramedicine program that you may never have heard about. Started in 2003 with Emed Health, evolving into the CONNECT Community Paramedic program in 2011. He provided examples of the details and issues encountered with the services that they provide.
For example, the CONNECT paramedics get a list of discharged patients with a LACE score of 11 or higher who have agreed to participate in the CONNECT program to reduce the number of readmissions within 30 days. The procedure is to make 2 phone calls and then do an unscheduled drop-in visit if the patient has not answered the phone.
Their experience is that only 40% of the high-risk discharged patients who agreed to participate in the program when they were discharged will interact with the CONNECT paramedic. Reasons for not interacting include:
- Bad telephone numbers or addresses that lead to a parking lot
- Patient refusal to participate in the program
- Patient “ghosting” the paramedic and can no longer be located
- Patient has died
For the 40% that do participate in the program, there is a statistically significant drop in readmissions within 30 days. In a two year study, CONNECT paramedics helped 269 patients. They estimate a savings of $1.8 million. That represents a savings of $6900 per patient when compared to their historical use.
The Big Surprise
The presenters noted an interesting change in who attended the course. Many of the EMS directors, community paramedic program directors, and fire-based coordinators showed intimate familiarity with the patient risk assessments done by their hospitals.
Some were already engaged with their hospital, their Accountable Care Organizations, and public health departments. This was not noticed when this seminar started in 2014.
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*The Charlson comorbidity score (C) is calculated as follows: 1 point for history of myocardial infarction, peripheral vascular disease, cerebrovascular disease, or diabetes without complications; 2 points for congestive heart failure, chronic obstructive pulmonary disease, mild liver disease or cancer, diabetes with end-organ damage, and any tumor (including lymphoma or leukemia); 3 points for dementia or connective tissue disease; 4 points for moderate to severe liver disease or human immunodeficiency virus infection; and 6 points for metastatic cancer.
El Morr C, Ginsburg L, Nam S, Woollard S. (2017) Assessing the Performance of a Modified LACE Index (LACE-rt) to Predict Unplanned Readmission After Discharge in a Community Teaching Hospital. Interact J Med Res 2017;6(1):e2 DOI: 10.2196/ijmr.7183
The featured picture is from the Connect Community Paramedic program in Pittsburgh.