DATE:
April 9, 2024
22
TO:
Board of Supervisors
SUBJECT
Title
REPORT BACK ON THE RURAL HEALTH POST-HOSPITAL DISCHARGE PILOT PROGRAM (DISTRICT: 2)
Body
OVERVIEW
On March 14, 2023 (6), the Board of Supervisors (Board) directed the Chief Administrative Officer to work with Grossmont Healthcare District to initiate a rural health post-hospital discharge program in Mountain Empire which includes the communities of Boulevard, Campo, Jacumba, Potrero, and Tecate. From July 2020-June 2023, the 30-day unplanned readmission rate averaged 12.1% for rural communities where Sharp Grossmont Hospital was the primary receiving hospital. While Sharp Grossmont Hospital has operated a post-hospital discharge program in more urban communities, no program has existed in rural areas.
County Fire partnered with the Health and Human Services Agency (HHSA), Grossmont Healthcare District, Sharp Grossmont Hospital, Mountain Empire School District, San Ysidro Health, and Southern Indian Health Council, Inc. to establish the pilot program. Launched in June 2023, the pilot program's medical team includes a County Fire/CAL FIRE paramedic (paramedic) and HHSA Public Health Nurse (Nurse). The Nurse reinforces the hospital discharge medical direction, assists clients with making follow-up appointments with a primary care provider, performs clinical and social assessments, provides case management services, and links clients to the County's Aging and Independence Services and Self-Sufficiency Services such as In-Home Supportive Services and CalFresh. The paramedic conducts voluntary defensible space inspections, looks for trip hazards and other household dangers, and can initiate an ambulance transport for medically critical patients, as needed. In the first six (6) months of the pilot program, the unplanned 30-day readmission rate has dropped to 4.0% for patients receiving those services compared to 13.9% for those who did not participate and resulted in an estimated cost avoidanc...
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