PROFILE: Cardiac and Stroke Care for Southwest Colorado

In 2012, CIVHC reported that the Upper San Juan Health Service District (Pagosa Springs Medical Center) received a three-year, $1.7 million award from the Centers for Medicare & Medicaid Services. We recently followed up on the outcomes of the project.

 Life-threatening conditions are especially terrifying when distance and terrain separate patients from treatment. Archuleta County is nearly 50% wilderness with the San Juan National Forest taking up much of the 1355 square miles from border to border. In 2012, Centers for Medicare & Medicaid Services (CMS) awarded Pagosa Springs Medical Center (PSMC) one of the first Health Care Innovation Awards to help address the difficulties of providing acute cardiac care in rural areas.

According to Elizabeth Howey, PSMC’s Innovation Project Manager, this award was ideal for Southwest Colorado for a number of reasons. “Cardiovascular disease is the second leading killer in Archuleta County. Many factors exacerbate the problem, including distance to cardiovascular specialists, inaccessibility of life-saving therapies, and public health issues leading to high rates of obesity and sedentary living.”

Started in July 2012 and completed in June 2015, the goal of the “Cardiac and Stroke Care for Southwest Colorado” program was to reduce cardiovascular risk and improve cardiovascular patient outcomes while creating a healthier community and reducing health care costs in southwest Colorado. To achieve the goals, the work was divided into four categories for implementation, each with measurable improvement results in either health outcomes and/or cost savings.

Community Outreach, Cardiovascular Early Detection and Wellness

PSMC expanded an existing cardiovascular early detection and wellness program to include public outreach and educational events with health screenings and consultations on lifestyle and behavior change. In order to reach further into the community, physicians, chefs, dietitians, and other professionals offered a lecture series where the general public learned about diabetes, healthy cooking , and stress management.

Over the three years, the wellness department screened over 1600 participants for multiple conditions and re-screened 632 who had been considered at-risk. The re-screened individuals displayed marked improvements with 58% of participants reducing Body Mass Index (BMI), 45% reducing LDL cholesterol, and 45% reducing systolic blood pressure, from initial screen to most recent rescreen.

The wellness program may translate into cost savings as well, based on projections from the Physical Activity Guidelines Advisory Committee Report, 2008. “Based on increased physical activity, reduction in risk of cardiovascular disease, diabetes, and certain types of cancer may save the healthcare system over $2 million dollars over the lifetime of these wellness participants,” explained Howey.

Telemedicine

Pagosa Springs’ remote location makes it difficult for patients who need access to specialized care. To help combat the need to transfer acute patients to different facilities, and for patients to travel long distances to access specialty services, PSMC incorporated telemedicine into their structure of treatment.

The PSMC Emergency Department partnered with the Colorado Digital Online Consultant to implement teleneurology, creating immediate access to specialists to help with diagnosis of stroke and inform life-saving care. PSMC staff has treated eight ischemic stroke patients since implementation.  The American Heart Association  estimated the lifetime cost of stroke in an individual patient to be over $100,000 (Heart Disease and Stroke Statistics, 2008 update).  Thus, the positive outcomes in stroke patients and avoided transport for patients ruled out for stroke may produce cost savings up to $1,866,000 according to Howey.

The clinic initially added telecardiology, but while conceptually useful, this intervention was ultimately discontinued as cardiologists and patients preferred face-to-face visits. As an alternative, PSMC partnered with Mercy Cardiology Associates to schedule on-site clinic days to ensure no patients missed treatment. Additionally, telephonic consultations between cardiologists and Emergency Department providers resulted in successful treatment of seven acute heart attacks.

Emergency Medical Services Critical Care Transport

In severely acute situations, most patients are transported by air, but this is a costly endeavor and may delay treatment when critical care is needed immediately. To overcome this challenge, PSMC began requiring all of their paramedics to be certified for Critical Care Emergency Transport which ensures the highest level of treatment during patient transfers. The paramedics are required to pass exams, attend continuing education classes, and re-certify as necessary.

PSMC’s paramedics completed certification in 2013 and in the past two years, 125 acute patients have been transported by critical care ground transport. Howey notes that this change “resulted in over $1,570,000 in cost savings,” based on data collected by PSMC comparing cost of critical care ground transport to average cost of air transport. Additionally, the Pagosa Springs EMS team was named 2014 Ambulance Service of the Year by The Emergency Medical Services Association of Colorado.

Patient Navigation and Outreach Paramedics

The practice of paramedics helping to fill gaps in care between home and the hospital has been gaining momentum across the nation. PSMC began implementing a community paramedicine program early into the funding period with local paramedics obtaining necessary certifications. The goal was to provide home visits to patients who were unable to make it to their provider either due to mobility or transportation challenges. However, as community paramedicine programs are relatively new to the health care setting, regulatory agencies are still in the process of determining regulations and best practices. PSMC made the decision to halt their program for the time being and await further oversight from the state of Colorado.

Howey describes Patient Navigators as “the hub for high-needs patients;” they help people make their way through the health care system and ensure that they understand their treatment and have access to the full range of services available. Based on data collected internally at PSMC for patients in the navigation program, this hands-on approach yielded impressive outcomes: 112 patients saw Navigators between April of 2013 and December 2014.  Of these individuals, nearly 100 percent reported high satisfaction with the program, 44 patients established relationships with primary care providers, 26 obtained health insurance, and 21 received prescription assistance.  In the 6-month period before referral into the navigation program compared to the 6-month period after referral, Emergency Department use for these patients decreased by 63 percent.

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PSMC had an uphill climb as they moved to plan and implement each of these initiatives. Extra training, increased volume, and interdepartmental communication were only some of the challenges they overcame. Adoption of Electronic Health Records and care coordination by the Patient Navigators helped smooth the way for many of the interventions.

Lack of reimbursement for their new programs remains an ongoing difficulty. “In the current fee-for-service model, many of the initiatives that continue past this project’s award-funded period are not reimbursed,” explains Howey. “This puts new financial strain on the medical center. However, Pagosa Springs Medical Center and its Board of Directors recognize the value to patients and families so they have determined that these services must be maintained for the best interest of the community.”

Though the final independent evaluation of the project is still underway by the National Opinion Research Center at the University of Chicago, based on the projections for the patients and programs cited above, PSMC indicates a possible total cost savings of approximately $5,659,000 in addition to the improved health outcomes of the population.  These cost savings are projections based on data collected by PSMC and have not been verified by an independent evaluator.

The leadership of Pagosa Springs Medical Center has proven its commitment to the health of the community by its ongoing support of this project.

The research presented in this article was conducted by the awardee. The reported results and cost savings may or may not be consistent with or confirmed by the independent evaluation contractor.

The project described was supported by Grant Number 1C1CMS330990-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Previously published as part of CIVHC’s Spotlight on Innovation series.

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