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COUNTY OF SIMCOE To: COMMITTEE OF THE WHOLE Section: Consent - Human Services - Paramedic Services Item Number: CCW 16-186 Meeting Date: April 26, 2016 Subject: Targeted Response Unit - Community Paramedicine Home Visit Pilot Update Recommendation: THAT Item CCW 16-186, being an update on the status of the Targeted Response Unit and the Community Paramedicine Home Visit Pilot Program, be received for information. Executive Summary: Item CCW 15-346 (October 2015), and subsequent 2016 budget approval supported the placement of a Targeted Response Unit in Ramara for a one (1) year trial period to measure the impact on emergency response times. With the response unit dedicated to Ramara Township since January 2016, the response time to our highest priority calls has significantly improved in the first quarter of 2016 compared to 2015. It was identified in Item CCW 15-346 that, due to the low emergency call volume in the Ramara area, there may be opportunities for paramedics to reduce 9-1-1 calls and patient transports to the emergency department for patients suffering from chronic diseases through the implementation of a home visit program. Further to this, 90 chronic disease patients who live in Ramara have been identified by their family physician as candidates for a home visit pilot. Following the provision of training to selected paramedics, home visits to consenting patients commenced on April 18, 2016 as part of the targeted response unit pilot program in Ramara. Background/Analysis: Code 4 Response Time Performance in Ramara (Jan 1 – March 31, 2016) The placement of the response unit in Ramara commenced January 2016. The chart immediately below shows the improvement in the County of Simcoe Paramedic Services for the highest priority calls (Priority 4) response time comparing Q1 2015 to Q1 2016 in Ramara Township. Staff will continue to monitor & report the Priority 4 response time in Ramara for the remainder of the pilot. May 10, 2016 Committee of the Whole CCW 16-186 2 The following chart illustrates the overall average response times for the highest priority calls (Priority 4) in Ramara Township taking into account all responding paramedic services. Community Paramedic Home Visits As outlined in Item CCW 14-359 (September 2014), the targeted response unit home visit program will consist of an initial visit and follow-up visits by the Community Paramedic with chronic disease patients identified & recruited by their primary care physician. A letter has been sent to 90 patients who have been identified by 17 primary physicians from the Couchiching Family Health Team. As of the writing of this report, 71 patients have been identified as residing within Ramara Township. Many of these patients have been contacted and scheduled for initial assessment in their home with a Community Paramedic. During home visits, paramedics review the patient’s medical history and undertake a physical exam based on disease-specific elements. Findings will be recorded directly into the electronic medical May 10, 2016 Committee of the Whole CCW 16-186 3 record (eMR) which is accessible to the patient’s primary physician. Follow-up visits can be prompted by the patient, the paramedic or the primary physician depending on the patient’s health. During home visits, the patient will be provided an information package that encourages them to notify their primary physician if they have any concerns with their current condition as the first line of contact. The primary physician can then request a follow-up assessment by the Community Paramedic. When exploring the concept of a targeted response unit in Ramara to look for opportunities for Community Paramedicine between 911 calls, staff reviewed Ramara and Orillia area paramedic transport call data for the period of January 1 to September 30, 2015. Frequent users for this nine (9) month period were defined as calling 911 for Paramedic Services four (4) or more times. On initial review, five (5) of the patients identified by the Couchiching Family Health Team for the home visit pilot were transported to an ED by the County of Simcoe Paramedic Services between January and September 2015. Neighbouring Paramedic Services will be approached to request sharing of data for the home visit patient group to develop a comprehensive understanding of the 911 & hospital system demand. Community Paramedic Selection & Training Further to Item CCW 16-010 (January), additional one-time Community Paramedicine funding received from the Ministry of Health and Long Term Care (MOHLTC) in November 2015 was used to fund seven (7) weeks of education for three (3) frontline Paramedics and one (1) Clinical Supervisor in chronic disease management to support the home visit program as part of the targeted response unit trial. The recruitment process was completed and three (3) front line Paramedics were selected for the home visit pilot program. The selected paramedics successfully completed their training through Centennial College including a total of seven (7) weeks of training incorporating didactic work, working in chronic disease and family physician clinics, health teaching programming and in field ride-outs in an existing home visit program. They were then put through final testing which incorporated a written exam and a practical Objective Structured Clinical Evaluation (OSCE). The OSCE consisted of five (5) practical scenarios inclusive of documentation/physician reporting. Areas of focus included accurate assessment and safe management of patients in their homes and identification of when physician consultations are indicated. Memorandum of Agreement The County of Simcoe and the Couchiching Family Health Team have signed a Memorandum of Agreement authorized in Item CCW 16-048 (January). The Memorandum of Agreement outlines the patient enrolment process, electronic medical record sharing of patient information, medical directives and performance reporting data requirements. Scope of Practice The Home Visit Community Paramedics conduct a detailed patient examination with special attention given to their identified disease process for which the patients were enrolled in the program. These chronic diseases include Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus (DM). Hand held blood testing equipment will be used to provide realtime lab quality blood chemistry results in minutes. The lab values can be reviewed with the primary physician by the Community Paramedic to assist with decision making about necessary treatments or medication adjustments that can be made in the home. Monitoring of other indicators of health such as weight, medication use, blood pressure, other vital signs and other assessment findings such as lung and heart sounds as well as health coaching and risk reduction. The paramedic findings will be directly entered by the paramedic into the patient’s electronic medical records and serve to keep their physicians aware of changes in their health status. Some home interventions and treatments can include IV/fluid therapy, evaluation of the impacts of current mediation regimes and adjusting medications on the spot when indicated. The paramedics can also initiate antibiotic treatment for chest May 10, 2016 Committee of the Whole CCW 16-186 4 infections, medications to reduce water retention and decrease load on the heart and adjust patient insulin levels as an example. Home Visit Response Unit Deployment The targeted response unit is deployed in Ramara Township twelve (12) hours per day, seven (7) days per week. The commencement of home visits began on April 18, 2016. Staff are taking steps to manage the deployment of resources so as to mitigate impacts on 911 responses in the area. Evaluation Program evaluation components will be shared between the County and the Couchiching Family Health Team to evaluate program success. These components include the number of Paramedic Service transports to an emergency department, emergency department visits & admissions prior to the home visit pilot and after the commencement of the home visit pilot as well as patient & primary physician satisfaction. Staff will continue to provide quarterly updates on the impact of the Targeted Response Unit – Community Paramedicine Home Visit Pilot Program. County-wide Response Times: As a result of the 2016 budget deliberations, County of Simcoe Paramedic Services implemented additional 12 hour Paramedic Rapid Response Units in the Town of Penetanguishene and in the Town of Innisfil. In review of response times during the first quarter of 2016, improvements in response times have been noted as a result of these additional resources. Please refer to Schedule 1 of this Item that outlines average priority four (4) response times for the first quarter of 2016 across local municipalities in comparison to the same period in 2015. Schedule 2 of this Item outlines the overall call volume comparison for the first quarter of 2015 versus 2016. There is an overall 6.2 % increase in call responses during this timeframe. Financial and Resource Implications: Funding for Community Paramedicine initiatives was initially announced in September 2014 with an initial deadline for use of the funds by August 31, 2015. This date was subsequently extended to October 31 2015 then again to March 31, 2016 with additional funds being allocated as outlined in Item CCW 16-010. On April 20, 2016 the Minister of Health and Long Term Care announced funding for Community Paramedicine initiatives would be continued through to March 31, 2017 (See Schedule 3). Details related to the funding continuation have not been disclosed as of the writing of this Item. Ministry funding will offset costs associated with the Community Paramedicine Home Visit Pilot Program. This funding supported the training tuition costs of $4,000 per person, paramedic backfill costs to staff the paramedic units while staff were away at training and will further support equipment purchases of $15,000. Relationship to Corporate Strategies: Strengthen Social, Health and Educational Opportunities: Establish partnerships to identify opportunities for strengthening human services and education to support improved health and wellbeing for our residents. May 10, 2016 Committee of the Whole CCW 16-186 5 Reference Documents: CCW 14-359 (September 23, 2014) CCW 15-346 (Oct 13, 2015) CCW 16-010 (Jan 12, 2016) Attachments: Schedule 1 – Average Q-1 Priority Four Response Times by Local Municipality 2015 v 2016 Schedule 1.pdf Schedule 2 – Q-1 Call volume by Local Municipality 2015 v 2016 Schedule 2.pdf Schedule 3 – Correspondence from Ministry of Health re: Funding Extension Schedule 3.pdf Prepared By: Merideth Morrison, Deputy Chief of Performance, Quality and Development Andrew Robert, Director and Chief, Paramedic Services Approvals: Date Jane Sinclair, General Manager, Health & Emergency Services Trevor Wilcox, General Manager, Corporate Performance Mark Aitken, Chief Administrative Officer April 29, 2016 May 3, 2016 May 3, 2016