Patients often feel most vulnerable during the transition from hospital to home – especially if questions linger, follow-up care is extensive or there’s any risk of complications. Knowing this, hospitals are finding ways to ensure patients don’t have to navigate discharge and recovery alone.
The Community Paramedic program at Kalkaska Memorial Health Center is a great example of this work. Based in the health center’s emergency department, the program supports patients during and after discharge in an effort to address concerns and prevent avoidable emergency department visits.
“At Kalkaska Memorial Health Center, our mission is to improve the health and quality of life for those that we serve,” said Jeremy Cannon, VP, chief nursing officer, Kalkasa Memorial Health Center. “To truly make an impact, we look beyond the four walls of our hospital and focus on understanding patient needs in their own environment.”
According to the National Library of Medicine, readmission within 30 days of hospital discharge has been linked to both short and long-term mortality. Proper care coordination before, during and after a hospital stay is critical for improving patient outcomes.
The program at Kalkaska engages providers across acute care, long-term care and primary care to identify patient’s risk for hospital re-admission. Team members often address discharge questions, concerns or confusion – whether it be difficulties managing acute or chronic conditions, missing resources at home, medication adjustments or new care needs.
Paramedics are available seven days a week to meet patients before discharge or contact them to schedule home visits within 24 hours. In the home, they identify barriers that may not have been apparent during the hospital stay and coordinate with primary providers, social work, pharmacy and the electronic medical record team to support comprehensive care.
“We are fortunate to have a hospital-owned emergency medical services agency operating through Kalkaska Memorial Health Center, allowing us to invest directly in the individuals who respond to our community members during their most vulnerable moments,” said Cannon.
Patients enrolled in the program have demonstrated significantly lower emergency department readmission rates. The work allows the teams at Kalkaska to better support patients and keep them where they want to be: home.
Those with questions or content ideas for the Hospitals Help series may contact Lucy Ciaramitaro at the MHA.