Description
Community Paramedicine (CP) represents an expanded role for prehospital clinicians to interact with clients/patients outside of the traditional health care system with the goal of improving health outcomes by connecting underserved populations with underutilized resources. Patient populations that may be at increased risk for failure of their outpatient health care plans and could benefit from the CP program will be identified through a variety of strategies including the discharge planning process for inpatients, emergency department discharge planning processes, frequent utilization of the emergency services system, and identification of members of vulnerable populations in communities that have historically faced barriers to successful health care outcomes. The goal of the CP program is to be able to identify a variety of challenges to the successful completion of health care strategies through visits with patients/clients in the community and facilitate successful completion of existing health care plans, and to identify novel and unrecognized opportunities for improvement in their health by assisting patients in accessing additional resources in the community. The CP program is not designed to duplicate existing resources in the community, but to develop expertise in the interaction with, and assessment of, clients/patients and facilitating the ability of clients/patients to access appropriate resources and be successful in achieving their health care goals.
The Pre?Hospital Clinician for Community Paramedicine is an expanded role to connect underutilized resources to underserved patient populations. The model designed seeks to mitigate long?standing health disparities experienced in both inner?city and rural areas. Using clinical outcome data, geo?mapped to specific communities, the Pre?Hospital Clinician will partner with multiple EMS agencies, as well as fire stations and Community Health Worker programs to serve communities and proactively address clinical needs that have historically contributed or led to admissions, readmissions, preventable Emergency Department and non?emergent 911 utilization, as well as leaving AMA or without being seen in the Emergency Department.
The UVA Health, Population Health department strives to improve the patient experience, the quality of care and outcomes while managing costs for multiple populations of people including vulnerable patients who face healthcare barriers, inequities and disparities, as well as to bring significant health concerns into focus so that issues can be addressed by matching needs to resource allocation as a means to overcome the barriers to healthcare that drive poor health conditions. Population Health seeks opportunities to collaborate internally and with other agencies and organizations to improve the health outcomes within the local, regional and state areas in order to best care for the patient populations served.
This program will include services and resources within the Population Health department such as personalized, in?home or community care, personalized advocacy, behavioral health, clinical and pharmacy support and escalation for interventions in real?time patient care including video and photo support. Patients can be eligible for enrollment into other Population Health programs and resources, as appropriate.
As defined by the Community Paramedicine Medical Director and subject to change, the scope of practice will include:
Patient assessment including vital signs, physical assessment as indicated/required, point?of?care (POC) testing including glucometry, blood count and chemistries, testing for infectious diseases, e.g. COVID 19, as needed
Administration of vaccines as indicated and/or directed
Obtaining specimens for laboratory testing including phlebotomy, viral testing, etc.
Obtaining EKGs as necessary
Wound care, assessment, and dressing changes
Provision of emergency care within their scope of practice as a certified EMS provider in Virginia as needed while accessing the 911 system and participating in that emergency care as needed.
Conducts review of the EMR and any documentation provided to the patient from recent inpatient, outpatient, or emergency department visits.
Review of current medications to ensure that the patient has been able to fill discharge prescriptions and that their medication supply is sufficient or if refills are needed.
Address any concerns or confusion about discharge plans and facilitate the filling of prescriptions, and attending any follow?up appointments.
Review any required health care equipment, e.g. home oxygen equipment, nebulizers, walkers or other gait assistance equipment, and ensure it is functional and assist the patient in obtaining the equipment if challenges have been encountered
Participation and facilitation in telemedicine opportunities, both previously scheduled as well as initiated during the CP visit
Provide patient and family/caregiver education and guidance at any point prior to, during, and/or after the inpatient stay, ED visit, ambulatory referral or outpatient appointment(s), including:
Serves as touchpoint and navigator between patients, patient care teams, outpatient SNF, IRF, ambulatory, specialty, and community Providers, appropriate resources, and UVA Health programs throughout the health system, local, regional, state and federal agencies.
Manages enrollment and assessments which can include: the PHQ depression inventory, SDoH survey tool, falls risk, social isolation risks, GAD, and/or other assessments, as needed.
Reviews all assessments and/or patient concerns, needs or requests to manage navigation of resource allocation including, but not limited to: Behavioral Health, Disease Management, Financial Assistance, Medicare/Medicaid enrollment/assistance
Can also refer to an advocate for transportation, scheduling of appointments and requests for provider referrals, social work and/or case management care plans, ICPs, medication reconciliation and pharmacy needs, PCP establishment referrals, housing, food insecurity, health literacy, safe environment and home accommodations for disabilities or physical challenges, and other discovered needs
Communicates to provider(s) or clinical team, as well as other agencies involved in the overall care of the patient and actions as part of the initial assessment
Documents all encounters in Epic and Population Heath systems and if needed, DRG, recent ED visits since last CP or primary care follow?up for the most recent 30, 60, and 90 days
Will stay up?to?date and manage any billable services in Epic
Will be familiar with electronic patient care records for prehospital care, and requirements for reporting of CP activities to the Virginia Department of Health, Office of Emergency Medical Services (OEMS)
All vitals are to be uploaded in Population Health platforms for Epic integration of data in real?time, share trends, concerns, issues with appropriate clinical care teams
Primary or Specialty Care LIPs and care teams will be notified through Epic of most recent visit and documentation note routed to appropriate LIP and/or clinical care team
Communicates regularly with patients to follow?up on progress and review/discuss barriers or challenges to health care, environmental, patient experience, or any flagged SDoH need, as well as potential adjustments to any identified need. This information is then shared with providers, clinical care teams, associated agencies of care including, but not limited to: Home Health, SNF partners, IRF, homeless shelter partners all with...
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