Q&A: How a $1.7 million grant improved Colo. health services

Updated Jan 12, 2015

In 2012, the Upper San Juan Health Service District in Pagosa Springs, Colo., gained national attention when it was awarded a three-year, $1.7 million Healthcare Innovation Grant from the Centers for Medicare & Medicaid Services. The grants were awarded to programs with compelling new ideas for delivering improved care with lower costs and better outcomes.

Even before receiving the grant, the rural health district, which serves about 13,000 residents living in southwest Colorado, had experience working with community partners and other stakeholders to fill gaps in care. In 2008, with the closest hospital 60 miles away in Durango and the nearest Level 1 trauma center more than 300 miles away at Swedish Hospital in Denver, residents revived a shuttered critical access community medical center, funding it with a bond initiative, state and federal grants and donations from affluent residents who owned second homes near the Wolf Creek Ski Area.

Calling it the Pagosa Springs Medical Center, the hospital now sees 1,000 patients a month in its primary care clinic and includes an emergency department, surgery center, lab, oncology suite and other departments. To improve the cardiovascular health of residents, in 2009, the hospital launched a wellness program, offering free blood pressure screenings, blood work to measure cardiovascular risk factors, nutrition counseling and exercise classes. The medical center also operates the four-ambulance Pagosa Springs EMS, which provides 911 ALS service to Archuleta County and the recreational wilderness areas of neighboring Hinsdale and Mineral counties.

Yet with a 2,000-square-mile coverage area and significant unmet primary care and specialist healthcare needs, they wanted to do more. “We wanted to bring our isolated community up to the standard of care you would find in an urban area,” says Becky Sproul, outreach paramedic, critical care paramedic and telemedicine coordinator. “That’s the focus of the grant.”

Though the grant has a community paramedicine component, that’s only part of it, Sproul notes. Key elements include:

• Expanding the wellness program.
• Using telemedicine robots to link stroke patients with neurologists at Swedish hospital, a comprehensive stroke center.
• Conducting paramedic outreach visits to patients recently discharged from the hospital and at risk of readmission.
• Training seven of eight paramedics as critical care paramedics able to transport sicker patients longer distances by ground, reducing the need for costlier air medical transports.

Sproul spoke with Best Practices about the programs underway in Pagosa Springs and how they’ve overcome barriers to getting them off the ground.

How excited were you to find out your agency was a grant recipient?
We were in company with some of the most incredible, well-respected medical services in the country. It was tremendous.

What types of initiatives is the Innovation Grant funding?
We’ve been able to expand the wellness program exponentially, reaching 600 patients a year. We now have neurology and cardiology specialty services available in our emergency department and primary care clinic through the use of telemedicine. And through patient navigation and outreach paramedicine, we’re following up with patients who have been discharged with a diagnosis of congestive heart failure, acute myocardial infarction, COPD and stroke.

We’re having referrals sent to us from the hospital, and we’re following up with those patients. The outreach paramedic—right now that’s me—makes contact via phone within 48 hours. We go through a questionnaire about their ability to manage their condition and what they are experiencing in terms of continuing symptoms. Then patients are offered a choice: either a follow-up visit in a primary care clinic within seven days or an outreach visit.

The outreach visit is protocol- and physician-driven. Each one of the diseases has a specific protocol and a list of diagnostics that can be done in the home by the outreach paramedic. If the primary care physician orders it, we can do point-of-care testing, which can include an EKG, blood work, a respiratory workup, A1c for diabetics, a comprehensive assessment, and any additional testing, assessing and education as requested by the primary care physician.


So the primary care physician determines what occurs during the outreach visit, not the discharge physician at the hospital?
When the patient is discharged, he or she is discharged with a set of discharge instructions. The only reference to that during my visit is to explain it if needed and to do medication reconciliation.

The outreach paramedic is an extension of the primary care physician, and a link between acute and primary care so that patient isn’t lost after acute care. Each and every outreach visit ends with a telemedicine consultation between the primary care physician and patient. We use a telemedicine conferencing device—basically an iPad with a telemedicine app—developed by the same folks at InTouch Health who provide our robot in the ER.

When I’m with the patient, I enter all of the information into the electronic health record—vitals, diagnostics, assessment findings—so it remains a part of the patient’s record. It’s also sent in real time to the primary care physician at the rural health clinic located at the hospital, who then reviews it while I’m on site. These are scheduled visits, so the physician then talks to the patient face-to-face and decides if anything else is needed. They can change meds, add meds, or if they have concerns about a finding, they may request the patient be seen quicker or taken to the ER. We also have an algorithm that if we find the patient is having symptoms that are serious, we can trip right back into 911.

There will be many more people who get phone calls than outreach visits. Many people who are discharged from the hospital have all the professional and social support they need and have no particular complications that are barriers to prevent them from managing their situation.

The patients who have the outreach visits are the high-frequency users. They need a lot more support and are people who come in and out of the primary care clinic and the ER.

The goal is to reduce 30-day readmission, so our minimum follow-up will be 30 days to ensure people have access to healthcare without involving emergency department or very expensive resources. I will become their point of contact when they are having difficulty, and from there we decide how to respond to that. It could be I’d go out there again. It will be their choice.

Are any other healthcare providers involved with patients seen by outreach paramedics?
We have a patient navigator who deals with logistics. We work incredibly closely. I handle clinical issues, while she will handle things like making sure patients are enrolled in the most appropriate healthcare insurance, making sure they have access to medications they need and the social support they need, whether it’s transport to physicians’ offices or specialty services. She deals with anything outside the clinical setting to support successful disease management. We do not take over any other role of any other healthcare provider—physical therapy, home health—though we may coordinate with them.

How many patients are you seeing through this program?
We’ve just started to be able to go out into the community, and right now we have four who are being followed by outreach. We’d ultimately like to handle between 1 and 2 dozen a month.

When you first proposed going into the home for scheduled visits, did you encounter obstacles?
We went to the Colorado Department of Public Health and Environment [which includes an emergency medicine and trauma services section] prior to the submission of the grant to clarify what community paramedicine would mean here in the state, and what barriers we would have to implementation of a program that is not well defined in the state. 
There wasn’t any reimbursement category called community paramedicine, nor defined boundaries. The solution we were presented with is if we wanted to implement a true community paramedicine program—which would involve sending paramedics with expanded roles to visit patients for scheduled visits into the home with no direct, real-time physician oversight—was to apply for a provisional home health license, which would put the community paramedicine program under the umbrella of home health.

That was a difficult situation. Home health wants very clear definition between the scope of allowed acts for community paramedics vs. nursing-based home health because there is potential for competition. We opted to look for other options to avoid jeopardizing relationships with home health.

The road we’re now taking, in part because of concerns not only statewide but locally and to ensure that partnerships we want stay solid, is making clear this is an extension of primary care. It’s more collaborative, with our patient navigator making sure people have access to all the services they are eligible for, including home health.

The community paramedicine definition and scope are still being formalized through the Colorado Department of Public Health. When all of those barriers have come down, we may revisit all of the options to make it the most effective in our community. At this point, we’re not relying on that legislation to move forward with this expanded use of paramedics.

Stroke care is another big focus of the grant. Was there a particular incident that got you interested in improving stroke care?
We had a call for a 55-year-old retired pilot who lived in a rural setting. All of a sudden, bam! This man who still seemed young and healthy had a knock-down stroke. It was obvious he needed to get to a stroke center right away, but it wasn’t something that we could do.

I tried to put together a field-to-stroke center transfer. I wanted to fly him but was told I couldn’t do that from the field. So I watched this guy be transferred by ground to a hospital in Durango. He was there for hours while they did different diagnostics and set up a ground ambulance transfer to take him to the Durango airport, where a fixed-wing plane took him to an airport in Denver, which then transferred him from that plane into another ambulance, and then to Swedish Hospital. By then it was hours and hours into it—too late for tPA. He suffered permanent disabilities.

I had come here in 2008 from an urban setting where I could have solved this problem in a few minutes. I was so frustrated knowing he would be severely disabled, and at my inability to access the level of care he needed in the time he needed it. I knew we needed to do better.

How are you aiming to improve stroke care with the grant?
In the past, if I responded to a call from someone having neurological symptoms, those patients would bypass our hospital here. They would be transported 60 miles to Durango, which can delay care.

Now, when patients come to our hospital, we can give them virtually immediate access, 24 hours a day, seven days a week, to a neurologist through telemedicine and the help of Swedish Hospital and Blue Sky Neurology, a physicians’ group.

We had a telemedicine robot provided to us by Swedish and have leased a second one, and we pay a fee for 24/7 access to neurology services. Our robot can give neurologists in Denver real-time, face-to-face interaction with the patient.

We have had several tremendous outcomes. These patients have an incredibly different quality of life now than they would have had before. Their deficit was tremendous when they arrived at the hospital, yet they have no lingering disability.