Serving Patient Needs Even After They’re Home


Shelley Stelzner, R.N., and James Pierson collaborated on the Community Para-medicine Program.

Once a patient leaves the hospital, staying connected can be difficult.

Sometimes care providers do not know what is taking place until the patient returns for a follow-up appointment, or is rushed to the emergency room in crisis.

NorthBay Healthcare has partnered with Medic Ambulance to connect at home with those at risk of heart failure. Paramedics with special training go to the homes of patients who have been discharged from local hospitals. The goal is to provide valuable home assessments and education to prevent complications that could land the patient back in the hospital.

The goal is to provide home assessments and education to prevent complications that could land the patient back in the hospital.

The Community Paramedicine Program began in September 2015 as a collaborative venture. The county’s designated ambulance provider initiated the pilot program through a healthcare improvement study sponsored by the California Emergency Medical Services Authority and California Healthcare Foundation.

“We immediately saw the value to those diagnosed with heart failure and pulmonary issues such as chronic obstructive pulmonary disease,” said Shelley Stelzner, R.N., who supervises the case managers who follow patients’ care plans. “The paramedics can take vital signs, assess a patient’s understanding of their discharge instructions, see if they are eating well and provide further education if needed.”

She added, “Because paramedics have extensive training in managing chronic diseases, and because they are so mobile, they are a great addition to a patient’s care team.”

“After they leave the hospital some patients think their care is finished and they often forget, or lose their enthusiasm for following all the instructions their physician gave them when they were in the hospital,” explained James Pierson, vice president of operations for Medic Ambulance. “Our team will visit them in the comfort of their homes to ensure they are recovering and doing what they should be doing to get better.”

A community-based approach like this, Pierson noted, supports patients who can benefit from follow-up care, education and personal contact. And it can reduce the over-all cost of health care in Solano County.

Paramedics and NorthBay’s case managers share results of patient assessments to determine appropriate follow-up care. It’s a program that has proven results elsewhere.

“Having experienced paramedics with additional training in patient assessment and clinical skills—and who are familiar with how we manage our patients’ care—leads to a more integrated approach to health care delivery,” explained Nicole Brocato, NorthBay Healthcare vice president and chief quality officer.

All in all, Brocato observed, “For North-Bay Healthcare, it’s a great partnership that will help our patients and reduce the cost of health care.”

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