Paramedic Coached ED Care Transitions to Help Older Adults Maintain Their Health

Older adults use the emergency department (ED) as an important source of acute care, making
20 million ED visits annually. Most older adults who visit the ED do not have conditions of
sufficient severity to warrant hospital admission; thus, they are treated and discharged
home. Unfortunately, older adults do poorly after being discharged home from the ED, with 20%
having repeat ED visits within 30 days. The ED-to-home transition has been identified as a
cause for these avoidable poor outcomes, but ED-focused interventions to improve this
transition have had inconclusive outcomes and have suffered from feasibility, sustainability
and scalability problems.

Coleman's Care Transition Intervention (CTI) has been validated to improve the
hospital-to-home transition, decreasing both hospital readmissions and costs. The CTI uses
coaches, usually nurses or social workers, to support patients being discharged home by
transferring skills to activate patients. Applying the CTI to the ED-to-home transition is a
natural extension, but it has not been evaluated in this unique and demanding setting.

In this study, the investigators will test the hypothesis that the community-based,
paramedic-coordinated ED-to-home CTI will improve community-dwelling older adults' post-ED
health outcomes and reduce costs. The investigators will evaluate CTI process outcomes by
testing if participants randomized to the CTI demonstrate better understanding of red flags
that indicate a worsening of their condition, implement medication changes more frequently,
and follow up with their primary care physicians more rapidly after ED discharge, as compared
to the control group. The investigators will also evaluate the effectiveness and
cost-effectiveness of the CTI by testing if participants randomized to the CTI have improved
Patient Activation Measure scores 30 days after discharge, have decreased frequency of ED
use, and decreased health care costs within 30 days of ED discharge. Additionally, the
investigators recognize that the CTI will not eliminate all repeat ED visits. Thus, they will
identify factors independently associated with repeat ED visits among CTI recipients such
that future programs can ensure their needs are adequately addressed.

This research will provide critical empiric evidence regarding the significant problem of
poor ED-to-home transitions. By leveraging the CTI, a widely available and efficient
intervention and paramedics, a highly-skilled and respected health care provider present in
all communities, the investigators will apply an innovative approach to improve older adults'
health following an ED visit. Through rigorous research, they will test the effectiveness and
cost-effectiveness of this approach, with a specific focus on ultimate sustainability and
dissemination.

Inclusion Criteria:

1. Age≥60 years

2. English speaking

3. Monroe County, NY or Dane County, WI resident

4. University of Wisconsin or University of Rochester affiliated primary care physician

5. Community dwelling (no prisoners, nursing home, assisted living residents)

6. Discharge home from the ED

Exclusion Criteria:

1. Previous study participation

2. Discharged to hospice

3. Homelessness

4. Followed by transition care team (e.g., from recent hospitalization)

5. Followed by intensive case management program

6. Emergency Severity Index 1 patients (highest acuity, as assigned by ED triage staff)

7. Unable to obtain consent from patient or proxy