Cathy Hostettler, DNP isn’t in EMS, but her indirect exposure to the industry over the years meant that teaming up with MedStar’s Mobile Integrated Healthcare program was an easy choice. The decision to do her Doctor of Nursing Practice dissertation research on MedStar’s Heart Failure Readmission Avoidance Program reflects the growing trend of collaboration across disciplines within the pre-hospital setting.
Hostettler ‘s retrospective research aimed to evaluate the MedStar program’s effect on readmission rates, costs of care and overall health status of enrollees who entered from October 2013 to September 2015. A total of 114 patients were originally included in the program, however 20 were unenrolled or died prior to completion and therefore were not included in subsequent analyses.
The median readmissions rate for heart failure patients across the United States is 23 percent, meaning that 22 patients in the program should have been readmitted within the first 30 days. In reality, only 18 patients were readmitted in that time frame, resulting in a rate of 19.1 percent and an almost $20,000 cost savings.
This cost savings were offset by higher than expected emergency department utilization. In fact, while the 94 enrollees were only expected to use the emergency department seven times in the first 30 days, they made a total of 53 visits for a cost of just over $56,000.
Hostettler hypothesizes that this higher than expected emergency department utilization rate was due to an initial underestimation that did not accurately reflect geographic patterns of emergency department use. She also expects that the number was confounded by enrollees who should have been jointly classified as high utilizers.
The health status of enrollees was measured using the EuroQol-5D-eL survey which provides a score of 0-100 based on patient responses to questions within five dimensions. Enrollees that graduated from the program saw an increase in their health status scores in all dimensions. There was one exception to this improvement, in which a subset of the enrollees saw a slight increase in feelings of depression and anxiety.
I asked Hostettler a series of questions on her decision to do research within EMS. Her responses have been edited for length and clarity.
COUNTS: AS A NURSE, WHY DID YOU DECIDE TO LOOK AT MIH/CP?
Hostettler: My experience with EMS goes back to my days as a staff ED nurse in an inner city, tertiary care hospital. A friend told me about the community paramedic concept. My knee-jerk response was that home visit nurses fulfill that role and paramedics need not apply. He persisted and helped me understand that home visit nurses are not usually available 24 hours a day and their agencies may not accept uninsured patients.
From my experience in the ED, I knew that patients in need often do not call their doctors, much less their home visit nurses when they need help; they call EMS. Because of this I realized that EMS was a very logical place for this intervention.
HOW DID YOU GET CONNECTED TO MEDSTAR?
MedStar is one of the premier implementers of mobile integrated health care. Since my project was for my doctoral program, I wanted to be able to narrow it down pretty well so that I could finish it and graduate in a reasonable period of time. MedStar’s Heart Failure Readmission Avoidance Program was much further developed than any of the others I did find, so I chose to study MedStar’s program as a possible prototype or basis on which other programs might be modelled.
Doug Hooten, Matt Zavadsky and Daniel Ebbett of MedStar were incredibly generous with their knowledge and data. Without them I would not have been able to do this project.
WHY DID YOU USE PDSA AS THE QUALITY IMPROVEMENT MODEL?
Because of the retrospective nature of my project, I was really looking at the success of the program, not at the philosophy of the program. As such, my project was more of a quality improvement project and the Plan-Do-Study-Act model is specific to quality improvement projects.
WHAT WAS THE EASIEST PART ABOUT RESEARCHING SUCH A NEW MODEL OF CARE?
The easiest part about researching this new model of care was the openness and transparency of MedStar.
WHAT WAS THE HARDEST PART ABOUT RESEARCHING SUCH A NEW MODEL OF CARE?
There is a lot of information available about mobile integrated health care, but very little of it is scientifically studied. Most of the more scientific studies are from the United Kingdom and some from Australia, New Zealand and Canada. A lot of the research I did to prepare for this project involved reading anecdotal reports. While these are great to read, they often do not help us understand what part of the intervention was useful and measure how useful it was.
The MIH-CP Performance Measurement project will be an incredible repository of information from across the country that will allow programs to benchmark their data against others and will provide documentation of measurable outcomes for programs.
WHAT DO YOU THINK THE MOST SIGNIFICANT FINDING FROM THIS RESEARCH PROJECT IS?
Mobile integrated health care programs are community-specific. They must address a community’s needs. The purse strings on health care are tightening. We are all called to do more with less. The EMS system is the way many patients access health care. For those who use EMS as their primary method of accessing health care, it is only logical that the EMS providers are perfectly positioned to help educate and link these patients to appropriate resources for continuity of care.
IF PEOPLE WANT TO LEARN MORE ABOUT WHAT YOU’RE WORKING WHERE SHOULD THEY LOOK?
I am hoping to present this at a national EMS conference soon. You can also read the full paper below.
WHAT ADVICE WOULD YOU GIVE TO A PROVIDER ATTEMPTING TO DO THEIR OWN RESEARCH?
I have five suggestions for EMS providers attempting research.
1. CHOOSE A TOPIC THAT INTERESTS YOU.
You are going to be working on this for a while, so make it something you are passionate about.
2. START WITH A SIMPLE PROJECT.
Sometimes you need to take baby steps in order to get to the destination. A quality improvement study is a great place to start and PDSA is a great tool for evaluating an intervention.
3. GET A MENTOR WHO IS EXPERIENCED WITH RESEARCH.
Formal research is a new world for most of us. The background research that must be done before trying to design a project is necessary and a good mentor will be able to help guide you to make sure you study what you want to study and how to study it.
4. FIND PEOPLE WHO AREN’T IN HEALTH CARE TO EDIT AND REVIEW.
The litmus test for understanding comes from whether or not someone with no exposure to the topic can understand what you are trying to say.
5. SHARE YOUR FINDINGS.
When you invest so much time and effort into creating a good project, you must share it with others. Sharing helps others with their work as well. Sharing more formal research helps others design their projects, benchmark their results against yours and replicate your study for reliability and validity.
Mobile Integrated Health Care: A program to reduce readmissions for heart failure
To view current outcome reports from MedStar’s MIH program visit http://www.medstar911.org/mobile-healthcare-programs
