Multimethod Process Evaluation of a Community Paramedic Delivered Care Transitions Intervention for Older Emergency Department Patients

Abstract

Objective

We assessed fidelity of delivery and participant engagement in the implementation of a community paramedic coach-led Care Transitions Intervention (CTI) program adapted for use following emergency department (ED) visits.

Methods

The adapted CTI for ED-to-home transitions was implemented at three university-affiliated hospitals in two cities from 2016 to 2019. Participants were aged ≥60 years old and discharged from the ED within 24 hours of arrival. In the current analysis, participants had to have received the CTI. Community paramedic coaches collected data on program delivery and participant characteristics at each transition contact via inventories and assessments. Participants provided commentary on the acceptability of the adapted CTI. Using a multimethod approach, the CTI implementation was assessed quantitatively for site- and coach-level differences. Qualitatively, barriers to implementation and participant satisfaction with the CTI were thematically analyzed.

Results

Of the 863 patient participants, 726 (84.1%) completed their home visits. Cancellations were usually patient-generated (94.9%). Most planned follow-up visits were successfully completed (94.6%). Content on the planning for red flags and post-discharge goal setting was discussed with high rates of fidelity overall (95% and greater), while content on outpatient follow-up was lower overall (75%). Differences in service delivery between the two sites existed for the in-person visit and the first phone follow-up, but the differences narrowed as the study progressed. Participants showed a 24.6% increase in patient activation (i.e., behavioral adoption) over the 30-day study period (p < 0.001).

Overall, participants reported that the program was beneficial for managing their health, the quality of coaching was high, and that the program should continue. Not all participants felt that they needed the program. Community paramedic coaches reported barriers to CTI delivery due to patient medical problems and difficulties with phone visit coordination. Coaches also noted refusal to communicate or engage with the intervention as an implementation barrier.

Conclusions

Community paramedic coaches delivered the adapted CTI with high fidelity across geographically distant sites and successfully facilitated participant engagement, highlighting community paramedics as an effective resource for implementing such patient-centered interventions.

Acknowledgments

We thank Hunter S. Lau, MD and Mikayla Ehlert, for their assistance with this study. We would like to particularly thank our community paramedics who participated in the study: Gail Campbell, Alex Cook, Mindy Dessert, Heather Lenhardt, John Lents, Raina Merchant, Peg Neufeglise, and Ché Stedman.

Disclosure Statement

The authors report no conflicts of interest related to the materials presented.

Additional information

Funding

Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG050504 and K24AG054560 and the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences award UL1TR002373. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.