Milwaukee – Aurora West Allis Medical Center and the West Allis Fire Department have launched a community paramedic program to help reduce hospital readmission for senior citizens in the Milwaukee suburb, the first of its kind in the area.
With the Transition in Care initiative, paramedics will make home visits to recently discharged, high risk patients from Aurora West Allis Medical Center to ensure they understand their medications, instructions from physicians, and conduct an overall assessment of the patient's health and living environment.
The concept is similar to other successful initiatives implemented in places like Boston, Massachusetts and Dallas, Texas that have seen a dramatic decrease in both 911 call volume and expensive, unnecessary visits to local hospitals.
Transition in Care will be led by Transition in Care registered nurses from the Aurora West Allis Medical Center, who will work with specially trained community paramedics from the West Allis Fire Department. These individuals have recently participated in community-based health care curriculum at the University of Wisconsin-Milwaukee College of Nursing.
Aurora West Allis Medical Center will make referrals of recently discharged patients to the West Allis Fire Department who could benefit from a home visit, based on the likelihood of readmission and historic indicators. Community paramedics will then visit patients and report the visit and any key findings to the transitions registered nurse at Aurora West Allis Medical Center.
All information will be added to the patient's electronic medical record at the Aurora West Allis Medical Center, and each patient in the program can expect at least one home visit in their first weeks home from the hospital to ensure a smooth transition.
The program between the hospital and the fire department is part of a larger strategy to build a healthier and stronger community.
"The Transition in Care program, working with the West Allis Fire Department, builds on our rich history of working closely with our community partners throughout West Allis," said Rick Kellar, president of Aurora West Allis Medical Center. "We know that many of our older patients struggle when they return home after a multi-day stay at our hospital. Patients will receive hands-on coaching and support from local first responders who can answer their questions and be a friendly face to welcome them back home. It's a win for everyone in the community."
The West Allis Fire Department implemented an initial community paramedic program in January 2015, when they began meeting with patients who recently were discharged and providing at home services.
After some 124 home visits with 29 patients, the fire department saw an 86 percent decrease in low-acuity 911 calls, or non-vital calls to emergency respondents, and a 71 percent decrease in visits to Aurora West Allis Medical Center's emergency department.
"The West Allis Fire Department is proud to work with our community partners at Aurora West Allis Medical Center to help people on the road to recovery when they return home from the hospital," said Captain David Bandomir, RN, mobile integrated healthcare coordinator with the West Allis Fire Department. "We've learned a great deal from our initial pilot program, and now, to formally implement the new Transition in Care program with the team from Aurora, we can begin to help more people across West Allis avoid unnecessary hospital visits by keeping them on track."
The Transition in Care program will be open to any resident of the city of West Allis ages 65 and older who have been assigned to a transition nurse and are discharged home or to an assisted living environment. All participation will be voluntary.
Aurora West Allis Medical Center will compensate the fire department on a per-visit basis, and data will be collected over time to ensure key metrics are met, including reducing unnecessary emergency room visits and 911 calls.
Aurora West Allis Medical Center has been a fixture in the West Allis Community since 1961. It is home to a leading emergency department, stroke center and the Aurora Women's Pavilion, where women of all ages and at all stages of health come for comprehensive, respectful care.