Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): a National Survey

Mobile Integrated Healthcare and Community Paramedicine (MIH-CP)

Insights on the development and characteristics of these innovative healthcare initiatives, based on national survey data

Presented by the National Association of Emergency Medical Technicians

Serving our nation’s EMS practitioners naemt.org

Sponsored by

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1Meaney PA, et al. Circulation. 2013;128:417-35

Authors

[ EDITOR ] Kevin McGinnis, MPS, Paramedic Jenifer Goodwin Program Manager, Community IMAGE PROVIDED BY KEVIN PIEPER/THE BAXTER BULLETIN Communications Projects Manager Paramedicine, Mobile Integrated National Association of Emergency Healthcare, Rural Emergency Care Medical Technicians (NAEMT) National Association of State EMS [email protected] Officials (NASEMSO) [email protected] [ EXECUTIVE EDITOR ] Pamela Lane, MA Scott Bourn, PhD, RN, Paramedic Executive Director President National Association of Emergency National Association of EMS Medical Technicians (NAEMT) Educators (NAEMSE) [email protected] Vice President of Clinical Practices and Research [ AUTHORS ] American Medical Response (AMR) IMAGE PROVIDED BY PINNACLEHEALTH/COMMUNITY LIFETEAM Matt Zavadsky, MS-HSA, EMT Englewood, CO [email protected] Chair NAEMT MIH-CP Committee Brent Myers, MD, MPH Director of Public Affairs Contents President-elect MedStar Mobile Healthcare î National Association of EMS Introduction p. 5 Ft. Worth, Texas Physicians (NAEMSP) î Survey Targets p. 6 [email protected] Director and Medical Director î Demographics p. 7 Troy Hagen, MBA, Paramedic Wake County Department of EMS î Community Needs Raleigh, NC Immediate Past President Assessment p. 8 Adjunct Assistant Professor, National EMS Management î Emergency Medicine Medical Direction p. 9 Association (NEMSMA) University of North Carolina î Partnerships p.10 Chief Executive Officer Chapel Hill, NC î Qualifications p.13 Care Ambulance Service [email protected] î Clinical Services p.14 Orange County, CA [email protected] î Case Study: Tri-County EMS p.16 Paul Hinchey, MD, MBA î Regulatory Environment p.18 Medical Director î Funding, Reimbursement p.20 National Association of Emergency î Case Study: Medical Technicians (NAEMT) Acadian Ambulance p.22 Medical Director Austin/Travis County EMS î Measuring Data and Austin, Texas Outcomes p.24 [email protected] î Case Study: Colorado Springs FD p.26 î Lessons Learned p.28 For more information and resources î The Future of MIH-CP p.29 on MIH-CP, visit naemt.org

Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): A National Survey

Over the past several years, two new types that can be drawn from the data. Analysis home health agencies, hospice agencies of patient care offered by EMS agencies have was provided by our author team, which and private insurers. Those contracts may generated tremendous interest within EMS includes several of the nation’s MIH-CP include payments for MIH-CP services based and the wider health care community. Called thought leaders, medical directors and on fee-for-service, a per-patient or capitated mobile integrated healthcare and community MIH-CP program administrators. fee, or other shared savings arrangements. paramedicine (MIH-CP), many believe these Yet most EMS agencies launching innovations have the potential to transform Survey finds much enthusiasm, MIH-CP programs have and continue to EMS from a strictly emergency care service significant obstacles fund these programs out of their existing to a value-based mobile healthcare provider The survey identified more than budgets – a sign of their dedication but that is fully integrated with an array of 100 EMS agencies that have worked worrisome from a financial perspective. healthcare and social services partners to diligently over the past several years to Compounding these challenges, the improve the health of the community. determine their communities’ needs, build newness of EMTs and paramedics taking on Though still evolving, MIH and CP partnerships to launch these innovative new responsibilities, albeit ones within their programs operating around the nation programs and contribute to solving the scope of practice as defined by state laws are providing a range of patient-centered key issues facing American healthcare. and regulations, has also raised concerns services, including: The promise of these programs among some regulators, nurses and other î Sending EMTs, paramedics or has garnered the attention of a broad health professionals who question whether community paramedics into the spectrum of stakeholders, ranging from EMS should be permitted to offer MIH-CP. homes of patients to help with hospitals to physicians groups, private chronic disease management and insurers and the Centers for Medicare and Data provides a national snapshot education, or post-hospital discharge Medicaid Services (CMS). The interest has To date, the data collected by this survey follow-up, to prevent hospital enabled some MIH-CP programs to secure and analyzed in this summary represents admissions or readmissions, and to grants to cover the initial development the only compendium of information improve patients’ experience of care. and operation of their programs. The from the nation’s currently operating î Navigating patients to destinations largest and most well publicized funding MIH-CP programs. Respondents, who such as primary care, urgent care, came from the CMS Innovation Center, included EMS agency directors, medical mental health or substance abuse which awarded grants to several EMS directors, and MIH-CP program managers treatment centers instead of agencies and their partners beginning in and practitioners, represent diverse emergency departments to avoid 2012 to study the effectiveness of MIH-CP communities and provider types, from 33 costly, unnecessary hospital visits. programs in achieving the Institute for states and the District of Columbia. î Deploying telemedicine to connect Healthcare Improvement’s Triple Aim: NAEMT would like to thank the patients in their homes with improving the patient experience of care, respondents who took the time to tell caregivers elsewhere. improving the health of populations and us about their programs. We would also î Providing telephone advice or other reducing the per capita cost of healthcare. like to thank NAEMT’s Mobile Integrated assistance to non-urgent 911 callers Outside of the federal grants, other EMS Healthcare-Community Paramedicine instead of sending an ambulance crew. agencies have been successful in securing Committee for developing the survey To add to the EMS profession’s grants from foundations, or in negotiating questionnaire, and our author team understanding of the development, contracts with partners such as hospitals, for generously providing their time and characteristics and status of MIH-CP in Medicaid managed care organizations, insights in analyzing the data. the United States, NAEMT conducted a comprehensive survey in late 2014 of the nation’s currently operating MIH-CP programs. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): This summary analysis reports the A National Survey results of that survey, and the conclusions Community paramedics from Baxter Regional Medical Center in Arkansas provide post-discharge follow-up visits and connect patients to primary care.

of the NAEMT MIH-CP Committee and included more than 50 questions asking respondents to describe all aspects of their MIH-CP program, including program activities, partners, agency demographics, medical direction, funding, revenue, goals and data collection. IMAGE PROVIDED BY KEVIN PIEPER/THE BAXTER BULLETIN In September and October 2014, the survey was distributed to approximately Survey Targets driven; patient-centered and team-based. 150 agencies that were either known Between April and October 2014, Examples of MIH-CP activities can include, or thought to have an MIH-CP program. NAEMT conducted a thorough search but are not limited to, providing telephone During that time, NAEMT continued to do to identify MIH and CP programs in the advice instead of resource dispatch; outreach to refine the list of agencies with United States. Sources included: providing chronic disease management, confirmed MIH-CP programs. î An earlier NAEMT MIH-CP survey preventive care or post-discharge follow-up; As of November 2014, we received widely distributed in 2013 by or transport or referral to care beyond a total of 137 responses. Of those, 26 NAEMT and several other national hospital emergency departments. did not have MIH-CP programs; 111 EMS organizations as part of the Because there is no strict definition did. Two did not provide any identifying Joint National EMS Leadership of MIH-CP, however, we had to make information and were eliminated; two Forum. judgment calls about inclusion. For were significantly incomplete and could î Media reports and Google searches. example, one EMS agency in a remote not be used. Four were duplicate answers î Other written materials, such mining area of Alaska indicated they from the same agency, so only one from as white papers and research utilized telemedicine to connect patients each agency was included, for a total of studies, that referenced MIH or CP with physicians in larger cities; this 103 completed surveys. programs. agency was not included because the Based on our search, we can say with î Interviews with EMS industry goal was to provide assistance with acute confidence that this represents the vast contacts. situations, not education, preventive majority of MIH-CP programs nationwide î Information provided by state EMS care or assistance with chronic disease at the end of 2014. offices. management. We also did not include EMS However, it should be noted that new î Phone calls and emails to individual agencies that described a high level of programs are coming on board every month, | 6 months - 1 year | EMS agencies. community involvement, such as providing so by now there may be more. Our search To determine inclusion as an MIH-CP community education on accident or falls also yielded many programs reportedly in program, we used the definition for MIH-CP prevention, teaching CPR, or conducting the final stages of development or awaiting contained in the MIH-CP Vision Statement, health screenings, but did not include any final grant or regulatory approval, such as | 2 - 3 years | spearheaded by NAEMT and endorsed of the other elements of MIH-CP. the dozen programs that are part of the by more than a dozen national EMS and California pilots slated for launch in the | > 3 years | emergency physicians’ organizations in Questionnaire covers all aspects first half of 2015 and six programs slated 2014. The Vision Statement defines MIH-CP of MIH-CP to launch in Michigan, also this year. These as being fully integrated; collaborative; data- The survey was crafted with the input were not included.

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100+ Agencies in 33 States, Wash., D.C. and Counting: Who’s Doing MIH-CP

Though the concept of community paramedicine had its start in rural areas, today mobile integrated healthcare and community paramedicine programs operate in a range of community types. [ COMMUNITY TYPES ]

| Urban | 54%

| Suburban | 44% states with MIH-CP | Rural | 36% states with no MIH-CP

| Super rural | 13%

[ RESPONSES ] Total number of MIH-CP program responses: 103 About half (53 percent) of MIH-CP *Information about MIH-CP in Alabama came in after the survey concluded. programs launched in the past year. Only 20 percent have been in operation two years or longer. Agency geographic service areas range from compact cities to sprawling rural and super rural regions. [ TIME IN OPERATION ] [ GEOGRAPHIC AREA COVERED ]

| < 3 months | 10% | Less than 250 square miles | 35%

| 3-6 months | 16% | 250 to 1,000 square miles | 35%

| 6 months - 1 year | 28% | More than 1,000 square miles | 29%

| Don’t know | | 1 - 2 years | 26% 1%

| 250 to 1,000 square miles | 35%

| More than 1,000 square miles | 29%

| Don’t know | 1% MIH-CP programs should strive to reach patients before they The Important Role of the become frequent users Based on this survey, EMS agencies Community Needs Assessment engaged in MIH-CP rely predominantly on data from individuals who utilize EMS services or have been cared for by the hospital system. There is broad consensus within EMS that MIH–CP programs are not This focus may hinder the MIH-CP system one-size-fits-all, but should be developed to meet community needs. from gaining a full understanding of the needs It’s also widely accepted that MIH-CP programs should not duplicate of their community, such as individuals who or compete with already existing services, and have not accessed the 911 or hospital system instead fill gaps in existing services. The way to but who may have significant care needs. determine where those gaps are is through As MIH-CP continues to develop, a long- Agree that a community needs assessment as part of term goal may be to reach members of the their MIH-CP the MIH-CP planning process. program is filling community before their health or psychosocial 95% a resource gap While that premise seems self- issues have deteriorated to the point where in their local evident, “community needs assessment” community they become frequent users of hospitals and is a term more familiar to public health EMS systems. professionals than first responders, and may mean many things to many people. The Agree that survey sought to describe the nature and their program is based on the source of community needs assessments Programs in existence for over defined needs within operating MIH-CP programs. two years were more likely to 74% of their community as According to survey responses, three expressed by local use a wider variety of data in stakeholders in four agencies (77 percent) report assessing community need. conducting a community needs assessment. Yet when a question about conducting a A narrow focus on patients already on the community needs assessment was asked in a slightly radar of hospitals and EMS may also restrict different way – whether they agree or disagree with the statement, “Your available payer sources. While focusing on program is based on a formal community needs assessment” – the responses this group of patients offers the opportunity were somewhat different. Only half (51 percent) agreed, 25 percent were for a “cost savings” source of revenue, it neutral, and 21 percent disagreed. This perhaps indicates confusion over what misses other potentially reimbursable patient constitutes a “formal” versus an “informal” community needs assessment. encounters from the large pool of individuals who have not been hospitalized. Sources of data, stakeholder input To identify these patients and gain a more Of agencies that conducted a community needs assessment, the complete look at community needs, MIH-CP most commonly used data source is EMS data (87 percent), followed systems should strive to use as many data by population demographics (63 percent), hospital discharge data (55 sources as possible to identify the needs percent), emergency department data (54 percent), public health data (41 of a much broader population within the percent), other data (12 percent), and law enforcement data (11 percent). community. Only 2 percent of agencies say they used no external data. It’s worth noting that programs in existence When asked to describe their community assessment, many agencies were more likely to use data other than report having meetings, roundtables and establishing working groups EMS data – 86 percent used population or steering committees involving a variety of stakeholders, including demographics, 62 percent used public health hospitals, social services, mental health, law enforcement, assisted living data, 62 percent used emergency department facilities, public and private payers and public health departments. data, 19 percent used law enforcement data, and 19 percent used other data – suggesting that longer-duration programs use a broader set of community health data when evaluating healthcare gaps in their community.

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Medical Direction Involves Multidisciplinary Collaboration

In emergency response, the role of the Others who provide medical direction and physician medical director is to ensure quality patient care. Responsibilities include advice to MIH-CP programs involvement with the design, operation, Primary care physicians (52 percent), evaluation and quality improvement of on-call emergency physicians (29 percent) and the EMS system. The medical director has specialty physicians (32 percent) are also called authority over patient care, and develops upon to provide medical direction or advice and implements medical protocols, policies regarding MIH-CP patient care. Other sources of medical direction and procedures. named by one or more respondents included other hospital physicians, The role of medical direction in MIH- physician assistants, surgical nurse practitioners, RN case managers CP is in some ways similar, with protocol and psychiatrists. development (88 percent) topping the list of This collaboration is evident in the more than half (51 percent) responsibilities. However, because MIH-CP of respondents who say that they obtained approval from partner focuses on coordinating care over a longer organizations for their clinical protocols. period than the typical EMS call, medical direction in the MIH-CP context may include additional responsibilities, often done in collaboration with primary care or other Breaking down silos: MIH-CP is team-based healthcare providers outside of the EMS From medical homes to care teams to accountable care organizations, the concept of agency. That can include the development collaborative, integrated, patient-centered care is a major theme of healthcare reform – and approval of care plans (62 percent), and MIH-CP. phone consultations (64 percent) and telemedicine consultation (18 percent). 77% Agree that their program is a multidisciplinary practice of medicine overseen by physicians and other healthcare practitioners

EMS Medical Director Role 70% Agree that their program is team-based and incorporates mul- 88% Protocol development/ tiple providers, both clinical and non-clinical approval 64% Phone consultation Agree that their program is patient-centric and focused on the 62% Development/approval of 96% care plans improvement of patient outcomes 42% Guidance on alternative destinations 18% Live online telemedicine consultations 1 in 4 agencies report using telemedicine in their MIH-CP programs. It was not specified whether that involves specific telemedicine applications or more Hours of medical direction/ oversight provided per week commonplace EMS activities, such as ECG transmission. Less than 10...... 79% 10 to 20...... 16% Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): More than 20...... 4% A National Survey MIH-CP Programs Partner With an Array of Healthcare, Social Services Agencies

Mobile integrated healthcare by programs to match each patient’s needs definition integrates with all entities that with the right resource. impact patient care and wellness. This integration is necessary for multiple reasons. Referrals go both ways Patients who have frequent contact Partnering works in two directions: the with EMS and hospitals often have multiple MIH-CP program can receive referrals from medical problems, comorbidities and the partner agency, or the MIH-CP program 69% complex psychosocial circumstances. These can refer patients to the partner agency. of MIH-CP programs receive health issues cannot be solved by a single According to survey responses, hospitals referrals from hospitals entity, but instead require the expertise are the most commonly cited source of of a variety of healthcare providers, social referrals to MIH-CP programs, with 69 services agencies and community resources. percent of MIH-CP programs reporting For EMS, these partnerships enable MIH-CP receiving referrals from hospitals, followed by C 69% K A D G 34% 34% 35% 28% F I B 22% H 32% 24% E 45% J 20% M 38% L 38% Organization Key 18% N A. Home Health 12% Organizations B. Hospices C. Hospitals D. Law Enforcement Agencies [ REFERRALS ] E. Mental Health Care Facilities The partner organization refers patients to the MIH-CP program F. Nursing Homes G. Other EMS Agencies A 66% I M K 62% H. Primary Care Facilities 48% 47% I. Public Health Agencies B H J L N 36% C E 53% 38% 44% 49% J. Physician Groups 35% 50% K. Community Health Clinics F 26% L. Urgent Care Facilities D G M. Social Service Agencies 14% 19% N. Addiction Treatment Centers

[ REFERRALS ] The MIH-CP program refers patients to the partner organization

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[ SOURCES ] 67% 58% 57% 47% 34% 27% of MIH-CP program hospital other healthcare EMS primary care general public 911 dispatch referrals provider practitioner physician referrals enrollment referrals referrals referrals

primary care facilities (45 percent), physicians Awareness of the value of MIH-CP programs groups (38 percent), social services agencies (38 percent), law enforcement (35 percent), appears to grow over time home health (34 percent) and community When isolating the data for programs with health clinics (34 percent). two or more years of experience, fellow EMS practitioners become the most likely to refer to MIH-CP programs (81 percent). While hospital referrals remain strong at 67 percent, referrals from other healthcare providers now 66% come in at 71 percent, followed by dispatch of MIH-CP programs refer and primary care, both at 52 percent. The patients to home health increased percentage of referrals from nearly all sources may indicate that over time, EMS practitioners and other healthcare providers accept MIH-CP and see the value it can bring. In seeking solutions for their patients, MIH-CP programs are most likely to refer their patientsto home health (66 percent), [ CHARACTERISTICS OF MIH-CP [ STAFFING ] followed by social service agencies (62 PROGRAMS ] Respondents report employing or con- percent), primary care (53 percent), tracting with many types of practitioners for MIH-CP programs mental health facilities (50 percent), | 75% | addiction treatment centers (49 percent), READMISSION AVOIDANCE | 77% | PARAMEDICS public health agencies (48 percent) and | 74% | community health clinics (47 percent). MANAGE FREQUENT | 26% | EMS USERS EMTs | 71% | | 21% | CHRONIC DISEASE FIREFIGHTER PARAMEDICS How patients come to the MANAGEMENT | 20% | attention of MIH-CP programs | 52% | PHYSICIANS ASSESSMENT & NAVIGATION TO MIH-CP programs are made aware ALTERNATE DESTINATIONS | 18% | NURSES of prospective patients from a variety of | 44% | PRIMARY CARE/PHYSICIAN | 17% | sources. Hospital referrals are the primary EXTENDER MODEL CASE/SOCIAL WORKERS portal to MIH-CP programs (67 percent), | 30% | | 16% | followed by referrals from other healthcare OTHER* FIREFIGHTER EMTs | 12% | entities (hospices, home health care, mental | 6% | OTHER* 911 NURSE TRIAGE health care and others) at 58 percent and | 9% | NURSE PRACTITIONERS primary care physicians (46 percent). | 5% | ALL OF THE ABOVE | 3% | EMS sources, including referrals from PHYSICIAN ASSISTANTS * mental health, hospice support, fall prevention fellow EMS practitioners (57 percent) and * pharmacists, crisis counselors, patient navigators, residents, dispatch (27 percent) are also important physical and occupational therapists in making MIH-CP programs aware of 35% 23% 18% 12% 11% potential patients. Re-tasking of Dedicated, Combination Dedicated, Other duty clinical full-time of full and part-time staff part-time

[ MIH-CP CLINICAL STAFFING MODEL ] Some MIH-CP practitioners are dedicated full-time to MIH-CP; others split their time between MIH-CP and emergency response or other duties. Partnerships Are About More Than Referrals

Partnering with stakeholders is not only assistance with staffing, supplies or other about referrals. Some partners provide resources, while others provide oversight [ OVERSIGHT/DIRECTION ] financial support, which may include direct and direction to MIH-CP programs. Who provides direction and payments for services, but can also include oversight?

[ DIRECT FINANCIAL SUPPORT ] Who provides direct payments for MIH-CP services? 33% 12% hospitals public health 15% 5% 4% 4% 2% agencies hospitals hospice public nursing physician health homes groups agencies 12% 11% physician primary groups care [ OTHER FINANCIAL SUPPORT ] facilities Who provides other financial support for MIH-CP services? 25% 5% 5% 4% 3% 9% 7% hospitals physician primary home mental home hospices groups care health health health facilities organizations facilities organizations

Is EMS doing everything it can to develop partnerships? With more than half (54 percent) of respondents Though 34 percent of respondents agree that “opposition reporting that their programs are a year old or less, it is from other healthcare providers such as physicians, nurses understandable that some may not have fully developed or home health is a significant obstacle to sustaining or the necessary partners within their communities. growing their MIH-CP programs,” an almost equal number Still, more than half (58 percent) of respondents view their (32 percent) disagree that opposition is a barrier. MIH-CP program as fully integrated into the healthcare And there is reason for optimism. system. Among programs in operation for two or more years, 66 percent agree that their program is fully integrated. EMS agencies report challenges establishing 87% Agree that support for MIH-CP partnerships for a variety of reasons, including: programs is growing among partners such as • other healthcare providers not understanding the EMS hospitals and other healthcare providers role in an MIH-CP program • fears among home health agencies that EMS participation in providing services in the home outside of answering 911 calls represents competition 96% Agree that the number of patients • potential partners not seeing a clear financial incentive served by their MIH-CP program will grow in the for partnering with EMS. next five years.

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61% 20% 13% 5% Developed College-based Used another Outside internally MIH-CP pro- contractor Experience Tops Qualifications gram’s training Sought in MIH-CP Practitioners [ TRAINING PROGRAM DEVELOPMENT ]

While the medical skills performed by EMS personnel participating in MIH-CP tend to be Wide variations in “Borrowed” training programs training, education consistent with their emergency response training include: Eagle County and experience, the focus and context of their and certification Paramedic Services, Wake clinical roles are very different. The practice of requirements County EMS, MedStar Mobile EMS is focused on rapid assessment, provision of may jeopardize resuscitative or supportive care within a narrow Healthcare, Mesa Fire set of protocols, and transport to a hospital- Department and FD CARES. reimbursement based emergency department. In contrast, the opportunities practice of MIH-CP is focused on longitudinal Training topics Overall, the survey data assessment, participation in an existing, Nearly all respondents require some suggests that the majority of multidisciplinary, interprofessional treatment type of additional training for their MIH-CP programs select experienced plan, and communication with and referral to practitioners. Clinical topics (67 percent), EMS practitioners for other members of the treatment team based on patient relations/communications MIH-CP programs, and that changing patient needs. Contextually, care shifts (66 percent), accessing community programs they require additional training from episodic evaluation and care of patients and social services (63 percent) and patient to perform these roles. independent of their existing medical care plan to navigation (59 percent) topped the list. However, the nature, duration longitudinal monitoring and adjustment of care as and content of that training is a part of a medical care plan. Length of training widely variable, suggesting that Asked what specific training or experience The length of training varied widely, as the preparation, knowledge qualifications are required of MIH or CP did the inclusion of clinical rotations or field base and level of skill of EMS employees, field experience was most often training hours. personnel who currently mentioned, with about one in four respondents [ CLASSROOM HOURS REQUIRED ] practice within MIH-CP systems specifying that MIH-CP practitioners had to is inconsistent. have between one and 10 years of field work 43% 18% 18% This inconsistency could Less than 40-80 hours 80-120 hours experience (usually paramedic). 40 hours raise concerns among potential Smaller numbers mentioned communications partners or payers about skills, positive attitude and a customer service focus 11% 4% 6% patient safety, clinical results 120-140 More than Don’t know as specific candidate competencies. As for specific hours 240 hours or patient experience, and credentials, several stated that critical care transport may reduce opportunities for paramedic training was required or preferred, while [ CLINICAL ROTATIONS/FIELD reimbursement from payers several stated other certifications were required, TRAINING HOURS REQUIRED ] who are more accustomed to including EMT, registered nurse, nurse practitioner 49% 16% 10% well-defined and seemingly and social work. Less than 40-80 hours 80-120 hours more clinically predictable 40 hours A few require some college or a providers of care. college-based community paramedic 16% 4% 6% EMS must continue to work certification. About one in four answered 120-140 More than Don’t know toward creating consensus hours 240 hours there were no special requirements. among stakeholders to define what MIH-CP clinical practice is, and from there create Hennepin Technical College in Brooklyn Park, Minn. and standards for skills, training, Colorado Mountain College are the two most-often mentioned education and proof of college-based training programs. competency. Clinical Services Seek To Avoid Unnecessary Emergency Department Visits, Hospital Stays While Improving Patient Quality of Life

The clinical services provided by MIH-CP respondents were most likely to offer Disease-specific care relies on practitioners can be broadly grouped into services that were already within the scope standard EMS equipment, skills three categories that may be part of an of practice of typical EMS agencies such as Disease-specific care offered by MIH-CP ongoing health maintenance program, blood glucose measurement (70 percent) is most often targeted at common or as part of a goal directed therapy or and blood draw services (41 percent). cardiovascular and pulmonary diseases such lifestyle modification. About one in five (19 percent) agencies as congestive heart failure (CHF), chronic 1 Assessment and evaluation report the addition of iSTAT (blood analysis) obstructive pulmonary disorder (COPD) point of care testing. A surprising number and asthma. Most of these services utilize 2 Post-discharge follow-up of agencies had expanded their services to equipment and training readily available to 3 Prevention and education include urine collection (26 percent) stool EMS providers, such as blood pressure (85 Common to all is that the MIH-CP program collection (13 percent) and throat swab percent), 12 lead EKG (70 percent) and oxygen facilitates this without the requirement cultures (12 percent). saturation measurement (78 percent). for a hospital or clinic visit, although the assessment may result in a recommendation [ RESPIRATORY SERVICES ] to visit a clinic or other healthcare provider. The goal is always to direct patients to the 78% Oxygen 69% most appropriate, convenient, least costly Saturation Check Asthma Meds/ 53% Education/ type of healthcare or social services provider Compliance Nebulizer Usage/ 41% 31% qualified to take care of their needs. Compliance Capnography Peak Flow Assessment Meter Usage/ 30% Education 28% MDI Use CPAP 1 Assessment and evaluation While the vast majority of MIH-CP programs indicate they assess patients, [ CARDIOVASCULAR SERVICES ] the survey does not make clear what is being done with the information gathered, 85% Blood Pressure including whether clinical decision-making is Check 70% EKG 12 Lead 40% autonomous, based on an algorithmic process Peripheral Intravenous Access or in consultation with the EMS medical director or other healthcare provider. Assessment and evaluation encompasses multiple service lines, including general [ ASSESSMENT AND EVALUATION SERVICES ]

assessment, which most often includes history 89% History and 61% 61% and physical (89 percent) and medication Physical Weight Check Post Injury 44% reconciliation (82 percent); along with Evaluation Stroke Assessment and Follow-up 8% laboratory tests and disease-specific care. Ear Exam

In-home lab services key to MIH-CP assessment and evaluation services [ LABORATORY SERVICES ] As with disease-specific care, 70% Glucose Check

41% Blood Draw 26% Urine 13% 12% Collection 19% Stool iSTAT Collection Throat Swab Culture

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The important role of patient navigation While many of the clinical Some MIH-CP programs, however, have call. MIH-CP practitioners are highly MIH-CP services provided seem significantly expanded their assessment and involved in providing these services to directed at managing patients at management of these disease processes their communities. home, the number of patients beyond what EMS would typically do. For that can be meaningfully impacted [ POST-DISCHARGE FOLLOW-UP SERVICES ] example, at least one program indicated and the cost effectiveness of this that they offered in-home diuresis of CHF 70% | Discharge follow-up approach remain to be proved. patients. For pulmonary disease, more than Another area where MIH-CP may 38% | Dressing changes/wound check half of respondents indicated they offered have significant impact on patient education related to asthma medication 31% | Post-surgery care outcomes and costs is through compliance (69 percent), nebulizer use (52 improved patient navigation, or 27% | Neurological assessment percent) and peak flow meters (31 percent). the direction of patients to the [ PREVENTION SERVICES ] appropriate resource. 2 Post-discharge follow-up Given the financial ramifications of 92% | Falls risk assessment extended hospital stays for non-acute care provide 71% | Social evaluation/support 59% and the financial penalties assessed on practitioners with training in hospitals with high rates of readmissions, 43% | Nutrition assessment patient navigation follow-up visits in the home in the hours or 25% | Psychiatric assessment days after hospital discharge is a potentially EMS agencies should make important way for MIH-CP programs effective use of their unique role [ PATIENT EDUCATION SERVICES ] to show value. Still, the data suggests in the healthcare system. EMS some uncertainty about the specifics of 62% | hypertension screening/education is often patients’ initial contact the services delivered – for example, 44 with healthcare. Patients may 59% | diabetes screening/education percent of respondents say they do stroke not know the optimal resource assessment and follow-up, while only 27 48% | physical activity screening/education for their current clinical need. Yet percent said they do neurologic assessments. they do know that they can call 28% | Dietary sodium reduction 911 when they need help and 3 Prevention and education 25% | Obesity screening/education EMS practitioners will come to Prevention and education play an their aid, quickly. These patients 12% | Cholesterol screening/education important role in preventing the next represent an opportunity for EMS unscheduled acute care event or 911 5% | Cancer self-exam awareness to have meaningful impact on healthcare costs by navigating each patient to the correct How long do patients stay enrolled in MIH-CP programs? resource at their initial contact The goal of MIH-CP programs is typically to “graduate” patients out of with the healthcare system. the program, which is often the point where they no longer rely on frequent That said, it’s important to note contact with the 911 or hospital system. Often, getting patients ready for that the ultimate goal of MIH-CP is graduation first means getting them connected with primary care, mental not merely to move the burden of healthcare providers and other services best equipped to take care of caring for patients to other parts complex medical and psychosocial issues. of the healthcare system, but to The average time patients are seen by MIH-CP practitioners is highly help patients get on the road to individual, with respondents reporting a range of less than 30 days (41 self-management, and better health percent), 31 to 90 days (36 percent), 91 to 180 days (14 percent) and greater and quality of life so that they need than 180 days (8 percent). fewer healthcare resources overall.

of MIH-CP programs 63% say their MIH or CP practitioners have an provide practitioners with training in accessing community 22% advanced scope of practice programs and social services 77% say their MIH or CP practitioners do not CASE STUDY

Tri-County Health Care EMS Rural, hospital-based ambulance provider takes referrals from physicians to reduce readmissions, improve access to care

In 2012, Minnesota became the first receiving referrals from hospital physicians hours, while the remainder comes out of (and still only) state to pass legislation and primary care physicians at the the EMS budget. authorizing Medicaid reimbursement of hospital’s five rural clinics. To achieve 24-7 community EMS-based community paramedics. “We provide post-hospital discharge paramedicine coverage, five community The rate is 80 percent of a physician visits for patients at high-risk of paramedics also answer 911 calls during assistant’s office visit charge, or $17.25 readmission,” says Allen Smith, Tri- their shift. per 15-minutes of patient interaction. County Health Care emergency response There is no payment for drive time, fuel manager. “We also work with primary care Starting small to prove safety, or supplies. physicians to help prevent unnecessary effectiveness To be seen by a community paramedic, ambulance trips and emergency Prior to launch, Tri-County sought a physician has to give an order, and it must department visits and to ensure patients input from community partners, including be part of a care plan established by the are accessing all of the health resources public health, mental health, home health physician. In December 2013, community available to them in the community.” and members of the public. Wanting to paramedics at Tri-County Health Care Tri-County community paramedics also proceed cautiously and build confidence in EMS, based in rural Wadena, Minn., began work closely with the hospital’s nurse care their program among physicians who they coordinator, and function as part of the rely on for referrals, they started with a hospital’s “medical home” clinical team. limited number of patients, Smith says. The Tri-County team also worked with Help from grants the hospital’s electronic medical records Funding for the program came from software experts to enable community a Minnesota Department of Health paramedics to access and input grant, which sent five paramedics to information into patients’ medical records. the community paramedic course at “Without that connection to the Hennepin Technical College. A three-year, electronic medical record, the information $300,000 grant from the South Country would not get back to the physician. At Health Alliance, a Medicaid managed care our rural hospital, we use almost no paper organization that serves a four-county charts,” says Dr. John Pate, EMS medical area, covers the cost of data analysis director and a family practice physician. IMAGES PROVIDED BY TRI-COUNTY and staffing a community paramedic 24 Community paramedics aim to see hours a week. The hospital also funds patients within 24 hours of referral. community paramedic staffing for 24 Enrolled patients receive a home visit and

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“We have to show that what we do is making an improvement in patients’ health, their ability to have a good quality of life and that they are satisfied with the care received.” – Allen Smith, Emergency Response Manager, Tri-County Health Care EMS

While EMS agencies in other states have emergency department charges in 2014. reported conflicts with home health, this is “A lot of the activities our community not an issue in Minnesota, he says. “We are paramedics do involve checking up on not home health. For patients to receive patients. They might go out and see if home health, they must have a payer an oxygen generator is working properly, source that covers it, and they must be or if they know how to use a nebulizer homebound,” Smith says. “We see patients machine, or whether the medicine they who don’t qualify for home health. We are have is what they were supposed to get,” also affiliated with a licensed home health Pate says. “In one case a gentleman was agency, and we also refer patients there.” sitting there trying to use a nebulizer but he hadn’t turned on the machine. He Getting on a path to financial would have ended up back in the ER. But sustainability how do you measure the impact of that? assessment; a review of their care plan and Even though the only available What is the true benefit?” education about managing chronic diseases; reimbursement is for the 15 percent of One strategy they plan to try is medication reconciliation; and any tests or patients who have Medicaid, Tri-County’s having patients fill out a quality of life treatments ordered on the care plan, such as community paramedics see patients questionnaire before and after enrollment. blood draws, wound care or injections. regardless of their insurance status. In 2014, They will have their first results in the next Patients are seen as often as daily for reimbursements from Medicaid totaled six months. two to four weeks. The first visit is typically about $10,000 – not enough to cover costs. “Part of our hospital’s mission statement 60 to 90 minutes; subsequent visits last 30 They hope to eventually have data to share is to achieve the Triple Aim, which is minutes. Every two weeks, a multidisciplinary with commercial insurers so that they can improving patient health, improving the team, which includes a community negotiate shared savings arrangements. patient experience of care, and reducing paramedic, social worker and nurse care One challenge, however, has been costs,” Smith says. “So how do I make sure coordinator, evaluates each patient’s progress deciding what data to collect and what my EMS agency is of value to my hospital? and determines if the patient is ready to outcomes to measure. Unlike urban areas, How do I ensure my people have jobs in the graduate or needs additional help. “It’s all frequent users are not a big problem future? It’s no longer, ‘You call, and we haul.’ individualized based on the patient’s needs,” for the Wadena area. They do have a We have to show that what we do is making Smith says. “There is a lot of gray to this.” few though, and estimate that their an improvement in patients’ health, their In 2014, community paramedics saw community paramedic program saved ability to have a good quality of life and that 203 patients with diagnoses that include $100,000 in ambulance transport and they are satisfied with the care received.” COPD, asthma, congestive heart failure and psychiatric issues. Most are elderly and need the extra support to continue to Tri-County’s tips for success live independently, Pate says. 1 Start small and gradually build acceptance of your program among physicians Other referrals come from an orthopedic and other healthcare providers who you will need to provide your program surgeon, who sends community paramedics with referrals. into the homes of knee and hip replacement 2 Think local. “My program wouldn’t work in Ft. Worth, or in New York City, and their program wouldn’t work here. Your program needs to fit local patients to conduct falls risk assessments, needs,” Smith says. and an area nursing home, which brings in community paramedics to do blood draws, tracheostomy care and feeding tube care to Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): prevent their patients from needing to travel A National Survey to a clinic or hospital. Regulatory Barriers Pose Challenges

EMS is governed by laws and than half of respondents (57 percent) regulations that vary from state to state. see statutory or regulatory policies as In launching MIH-CP programs, one obstacles to MIH-CP. challenge for agencies is determining It should be noted these responses whether their state’s statutes and include only the states where there MedStar Mobile Healthcare paramedics conduct regulations allow or prohibit EMS from post-discharge home visits with patients in Ft. Worth. engaging in MIH-CP. Surveys of state EMS offices by “Don’t give up. It’s going to the National Association of State EMS Officials (NASEMSO) indicate that in be one of the most difficult a large number of states, laws and things you do as an EMS regulations are interpreted as permitting agency due to all of the MIH-CP; in others, statutory and/or regulations. If you remember regulatory language is interpreted as this is the next step in prohibiting it; while some have not yet helping the citizens of interpreted their statutes. Anecdotally, 80% your jurisdiction and you Agree that their EMS agencies frequently report that it programs are legally can be hard to discern what, if any, repeat that to anyone who compliant at the MIH-CP activities their local regulations questions the program, you local, state and or their state attorney general will maintain a positive federal levels would permit. attitude and be a champion It is perhaps for that reason that more for your program.” – Survey respondent

are operating MIH-CP programs. In the states where there are no MIH-CP programs, prohibitive statutes or regulations, or perceptions of those, Agree that statutory or regulatory policies are a significant obstacle to may be a reason why programs are sustaining or growing their MIH-CP program 57% unable to get off the ground. Another possibility is there isn’t enough interest in MIH-CP yet.

Moving ahead with innovation despite barriers Even in states in which regulations are Disagree that statutory or regulatory barriers get in the way of their seen as barriers to MIH-CP, some EMS 23% MIH-CP program agencies are finding ways to work within

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the law to launch programs. î In California, state law says EMS “Regulations must be updated to support this kind of work.” must respond “at the scene of an – Survey respondent emergency” and must transport patients to the hospital. But another statute permits pilot programs that use healthcare What’s in the law that makes it difficult for personnel in new roles to study improving patient outcomes and EMS to take on these new roles? reducing costs. In mid 2015, about a dozen California EMS agencies are slated to launch community paramedicine pilots. î When Maine’s state EMS officials wanted to bring CP to the state, the Attorney General issued an opinion stating that the Maine EMS Board could not authorize community paramedicine because it is outside the scope of emergency response. The state legislature approved an amendment to the EMS statute authorizing 12, three-year While EMS is often described as being at the crossroads of public CP pilots, which are currently safety, public health and medicine (and so, perfectly positioned to underway. provide MIH-CP), it is more common that EMS is more narrowly defined î In Michigan, the state EMS office in law or regulation as an emergency service. determined their state laws did not When asked to describe what legal barriers were hindering their prohibit MIH-CP. After consulting programs, the most commonly cited issues were regulations that with the state Bureau of Legal confine practice to 911 emergency response. Several mentioned there Affairs, the EMS office determined is no legal ability to transport patients to destinations other than the that EMS agencies could apply emergency department. for approval of CP programs via a Home health licensing laws were also mentioned by several “special study,” three-year pilots to respondents. In conducting scheduled, in-home visits, there is the test new healthcare strategies. potential for MIH-CP services to be interpreted as falling under home So far, at least two programs health regulations. In Colorado, some MIH-CP programs have sought have launched and six more home health licenses, while one respondent from Virginia noted that are approved. the state Office of the Attorney General issued an opinion that MIH- î On the other end of the spectrum CP programs wanting to perform in-home services should seek home is Texas, a delegated practice state, health licenses. meaning there is no statewide A few also mentioned the lack of clarity in the law, confusion over scope of practice for EMS. Instead, which regulatory body should have jurisdiction over EMS practitioners medical directors determine what when acting outside of the 911 response capacity, difficulties working EMS can do – perhaps one reason with city and state attorneys and hospital legal counsel, and questions why Texas is considered a national about whether MIH-CP activities are within the paramedic/EMT scope leader in MIH-CP. of practice.

Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): A National Survey Limited Funding, Reimbursement for MIH-CP Makes Long-term Outlook Cloudy

Reimbursement for transport and mileage is the bread and butter of EMS agencies. While public organizations, such as fire departments, often receive substantial tax support to fund operations, even these organizations say they are increasingly reliant on billing Medicare, Medicaid and private insurance to keep up with the increasing volume of medical calls. 36% When it comes to MIH-CP, however, there is only one state in Generates which community paramedicine is a billable service, and even revenue there it’s only for patients with Medicaid. [See Tri-County Health Care Case Study]. Unable to bill for services, the vast majority of EMS agencies operating MIH-CP programs say the lack of 64% payments and reimbursements is an obstacle. No revenue

Agree that reimbursement/funding 89% is a significant obstacle

Yet respondents were not entirely pessimistic about their financial prospects. When asked if they agree or disagree with [ ARE MIH-CP PROGRAMS GENERATING REVENUE? ] the statement “Your program is financially sustainable,” the most common answer was “neutral,” perhaps indicating that many are simply unsure.

Few MIH-CP programs generate substantial revenue – Yet While many agencies fund their programs out of their own operating budgets, some have secured contracts that provide payment for MIH-CP services. Of the 99 respondents who 34% 41% answered the revenue questions, 36 – about one in three – Agree Neutral report that their program generates revenue. For the most part, the revenue is minimal. Seven receive under $10,000 annually; four report earning between $10,001 and $25,000; and one generates between $25,001 and $50,000. 20% A few MIH-CP programs bring in considerably more. Four report Disagree earning between $50,000 and $100,000 annually; two bring in $100,000 to $150,000 annually; two receive payments of $300,000 4% Don’t know to $500,000; and two generate $500,000 or more annually.

[ IS YOUR MIH-CP FINANCIALLY SUSTAINABLE? ]

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A Wake County (N.C.) EMS advanced practice paramedic conducts outreach.

Economic model Is the financial outlook more promising than for MIH-CP these early revenue figures suggest? payments In the overall cycle of testing new business models, it is very When asked how the common for innovations to take years to generate enough revenue to MIH-CP program receives be considered a financial success. This is especially true in healthcare, payments, the most common where EMS-based MIH-CP services are still in their infancy. It is also answer was fee-for service very typical for healthcare innovations to take years to generate (15 agencies, or 15 percent). enough outcome data to become recognized as a valuable service Eleven agencies indicate line for payers to invest in. Healthcare payment policy is not often they receive an enrollment considered nimble. For most EMS agencies, CMS (Medicare and Medicaid) represents the lion’s share of revenue derived from fee-for-service transports, and making major changes in CMS payment policy literally require 50% an act of Congress. Compounding this issue, most commercial payers of respondents believe generally follow CMS guidelines for payment policy. Therefore, it is their program will not surprising that the revenue rates are so low during this time of continue to grow as a innovation incubation. source of revenue for It should also be noted that there are other potential sources of revenue outside of direct payments for services, including taxpayer their EMS agency support. Agencies that rely on tax revenue for a portion of their fee or fee-per-patient, 12 budget may have their programs funded, in whole or in part, through say they operate in a shared tax dollars if the community values the MIH-CP services or sees savings model with partner MIH-CP services as an overall means of cost savings. organizations, and two say Yet these survey findings also underscore the urgent need to prove they receive a fee for referral. that value – to the community, to private insurers, to CMS and to other Twenty-three respondents entities that may provide payments. For insurers or other external indicated they were receiving sources of payments, demonstrating value will likely include showing a other sources of revenue, with reduction in expenditures coupled with effective patient outcomes and grants most commonly cited. positive surveys of patient experience.

[ ANNUAL OPERATING COSTS OF MIH-CP PROGRAMS ] 2% 16% 16% 5% 12% 11% 13% 11% 13% $0 $1- $10,001- $25,001- $50,001- $100,001- $150,001- Over Don’t $10,000 $25,000 $50,000 $100,000 $150,000 $300,000 $300,000 know

Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): A National Survey CASE STUDY

IMAGE PROVIDED BY ACADIAN Acadian Ambulance Private ambulance company partners with Medicaid managed care organization to improve pediatric asthma care

Acadian Ambulance, which serves 30 Richard Belle, Acadian’s mobile healthcare know how to get plugged into community counties in Texas, 33 Louisiana parishes and continuing education manager. resources that are available to them.” and one Mississippi county, is one of For one elderly woman, medics the nation’s largest private ambulance arranged mail-order prescriptions to Expanding to diabetes, pediatric providers, answering half a million calls for prevent her from calling 911 every time asthma care service annually. she ran out of her medications. They Encouraged by their success, Acadian In 2013, inspired by the work being reduced trip hazards in her home, and began outreach to potential partners. The done by MedStar Mobile Healthcare in Ft. worked with United Way to have a rotted first pilot to come out of that was with Worth, Texas, Acadian decided to launch an staircase replaced and a railing installed. a private insurer, which contracted with MIH-CP program. The Acadian team started Another patient was a paraplegic who Acadian to do home visits with diabetic where many EMS agencies begin – by suffered from frequent, painful urinary patients to cut down on emergency analyzing EMS data for frequent 911 users tract infections but could not get in to see department visits. During the four-month who might benefit from better navigation a urologist quickly enough, so he went pilot, Acadian medics provided education and a more coordinated approach to care. to the emergency department. Acadian’s on managing diabetes, and supplied medical director got involved to get him an glucometers and test strips to those who Gaining experience with appointment. The man no longer calls 911 didn’t have them. Though early results frequent users with regularity. showed patients A1C levels had improved, Their search identified about 15 people Of those initial 15 patients, all but the insurer ended the pilot without in the Lafayette, La. area who were calling one has significantly curtailed their use explanation, Belle says. 911 at least once a week. Paramedics of 911 and the emergency department, About a year ago, Louisiana Healthcare arranged home visits with them. Many had Belle says. “There is a small population of Connections, a Medicaid managed complex medical and mental health issues people out there who are system abusers, care organization, began working with that required individualized solutions, says and many of them have substance abuse Acadian on a pediatric asthma problems,” he says. “But most are using intervention. Acadian’s Chief Medical 911 because they don’t have a primary care Officer Dr. Chuck Burnell worked with provider, they don’t have transportation Louisiana Healthcare Connections’ clinical to get to a primary care provider or to team to develop protocols. get prescriptions filled, or they just don’t “Last summer, we were looking for

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“After six months, we’ve seen better management of asthma for the children in this program. Their emergency room utilization has decreased and their medication compliance has improved.” – Lani Roussell, Quality Improvement Manager, Louisiana Healthcare Connections

a way to help our young members with Roussell says. “Together, Louisiana they need to contact the child’s physician. asthma, which is particularly problematic Healthcare Connections and Acadian Don’t wait and then go to the emergency due to environmental factors in our state. Ambulance are developing innovative ways department,” Belle says. Asthma causes more hospitalizations than to address pediatric asthma and making a any other childhood disease and is the lifelong difference in the health, education Moving toward financial viability number one cause of school absences from a and happiness of Louisiana’s children.” Acadian medics receive a fee per visit chronic illness,” says Lani Roussell, Louisiana Today, 19 families are enrolled in the from the managed care organization. But it Healthcare Connections quality improvement program; 14 have a first visit scheduled still costs Acadian more to administer the manager. “Because of their reputation for and 23 have expressed interest. Among program than it recoups, Belle says. With the quality service and technological innovation, participating families, the response has program slated to run until the end of 2015, we partnered with Acadian Ambulance on been overwhelmingly positive, Belle says. next steps will be re-negotiating their fee a pilot program to bring mobile healthcare Some of the “fixes” are relatively easy, with the managed care organization, adding to New Orleans area children with asthma. such as explaining to one family that more patient groups, and sharing their The mobile healthcare program identifies their asthmatic toddler should not sleep positive results with other potential partners. Louisiana Healthcare Connections members in a crib with two cats. Others are more “This program will be revenue who have pediatric asthma and are at a high difficult. Some families live in substandard generating for Acadian in the coming risk of emergency room utilization. Then housing with mold and pest infestations. months,” Belle says. “We are going to take over the course of four weeks, Acadian “We do very little clinical care. Most of these results to other hospital systems, Ambulance’s trained paramedics visit the what we do is education and navigation and public and private payers as a proof member at home to conduct preventive of patients, getting them to understand of concept, and show them how much screenings, perform an in-home risk that when their child starts to feel bad, money they can save by doing this.” assessment, and provide personalized health coaching on managing asthma.” Acadian’s tips for success Program set to expand further 1 Frequent user programs are a good place for EMS agencies to start developing Acadian has received referrals for an MIH-CP program. The agency can use internal data, and can use any 362 children. An unexpected challenge successes to demonstrate effectiveness to potential partners. was that a high number (133) were 2 Tap into your local community health worker network. Community health unreachable; either the address and workers, who may be volunteer or paid workers, typically have little medical training, but instead conduct outreach, provide social support, do informal phone on record with the insurance health behavior counseling and provide basic health education or screenings company were incorrect, or the family to members of the community. In Louisiana, the community health workers didn’t return calls, Belle says. network shared valuable information about community resources such as social Thirty families refused to participate; services, non-profits and charitable organizations. Acadian mobile healthcare 107 are considered “inactive” because the paramedics also attend community health worker monthly meetings. family expressed interest in participating 3 Understand that every patient group has different needs. The children in and received one or more home visits but the Medicaid pediatric asthma group, for example, had a pediatrician. So one then became unresponsive. As of March goal was to get the family to rely on the primary care provider instead of the 2015, 33 families had completed the emergency department. In a frequent user group, however, many patients are likely to lack primary care access, posing a different challenge for the mobile program and graduated. healthcare team. “After six months, we’ve seen better management of asthma for the children in this program. Their emergency room Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): utilization has decreased and their A National Survey medication compliance has improved,” Measuring Outcomes and Patient Satisfaction to Show Value

With healthcare entities increasingly MIH-CP must grapple with what to expected to show that treatments measure and how to measure it and interventions are worth the price, 64% That so many respondents indicate they developing systems of collecting and collect pre-MIH-CP enrollment collect and analyze data for both MIH- analyzing data is a high priority across the CP program development and outcome healthcare spectrum. healthcare utilization, while measurement is very encouraging. This Traditionally, EMS hasn’t been expected 56% collect post-enrollment means that the basic infrastructure and to collect or report performance data, usage too commitment to tracking and reporting data with the exception of response times and is in place, a key step in demonstrating the resource deployment. But it’s only a matter share with other entities, including local value proposition that payers may want to of time before major payers such as CMS government or other local stakeholders see as a condition of widespread payments and private insurers will expect EMS to (36 percent), their state Medicare/ or reimbursement for MIH-CP services. transition, along with the rest of healthcare, Medicaid office (21 percent), state public But determining the most important away from strictly fee-for-service health department (20 percent), insurance data to collect, the most feasible way to reimbursement and toward reimbursement companies (15 percent) and CMS (12 collect it and how to share it brings up that takes into account costs and outcomes percent). Only 7 percent say they don’t complex questions that all of healthcare is – in other words, value. share data. grappling with – MIH-CP included.

[ DATA COLLECTED BY MIH-CP PROGRAMS ] 90% | Patient demographics | 86% of respondents say their | Pre-MIH-CP healthcare utilization | 64% MIH-CP program collects data | Healthcare utilization during enrollment | 60% In the MIH-CP context, collecting and reporting data internally and to healthcare | Post MIH-CP healthcare utilization | 57% stakeholders is beneficial for two major reasons. First, data can prove to the EMS | Patient satisfaction | 54% agency and partners that the program is having the desired impact. Second, if | Expenditure data | 47% the program is not achieving the desired outcome, the data serves as the foundation | Income data | 12% for developing, testing and comparing alternate models and strategies. [ OUTCOMES MEASURED BY MIH-CP PROGRAMS ] Consistent with the importance of partnerships and collaboration in MIH- | Decrease high frequency system users | 76% CP, 65 percent of respondents indicate that they share data with their MIH-CP | Decrease hospital readmission rate | 72% partners. Fewer but still sizable numbers | Patient outcomes | 71%

| Customer satisfaction | 55%

| Per patient episode cost | 40%

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Community paramedics from North Memorial Ambulance Services in Robbinsdale, Minn. seek to prevent 911 calls. IMAGE PROVIDED BY DAVID JOLES/MINNEAPOLIS STAR TRIBUNE

In this survey, only one agency reports 59% Rate their program as highly or somewhat successful in achieving patient collecting and reporting patient health somewhat successful in reducing reliance satisfaction status as a core measure. Though the on the emergency department for a specifics of data collection may vary from defined group of patients With which groups of patients do agency to agency, the patient’s assessment MIH-CP programs report success? of their health status upon enrollment and MIH-CP programs are most likely at graduation is a key measure that should to report success with frequent 911 be used by all EMS agencies conducting 81% users – 54 percent say they are highly MIH-CP programs. of programs in operation for or somewhat successful in improving In addition to challenges in determining two years or longer report outcomes for this group while 51 which outcomes to measure, there are success in reducing costs, percent say they are highly or somewhat also technological obstacles, including the successful in reducing per patient dismaying inability of many electronic patient 911 use and emergency healthcare costs. care reporting (EPCR) systems used by EMS department visits for One patient group that seems to to fully integrate with the data systems of defined groups of patients be particularly challenging for MIH-CP hospitals and other partners, and vice versa. programs is patients referred because of Another issue is that many EPCR systems 46% Rate their program as highly or substance abuse or alcoholism. About used by EMS are not designed to collect somewhat successful in reducing 30-day 26 percent of MIH-CP programs report longitudinal data. The incompatibility of readmissions for specific patient groups improving outcomes for this group, while various data systems and barriers to health 62% Rate their program as highly or 18 percent report lowered healthcare costs. information exchange is hardly exclusive to EMS or MIH-CP, but is an area that needs [ MIH-CP Programs Report Improved Outcomes for Various Patient Groups. ] attention to make possible the bi-directional Improved Too Soon Not flow of information between the Outcomes To Tell Applicable multi-disciplinary teams involved in MIH-CP. Frequent 911 users 54% 0 16% COPD, asthma, diabetes 54% 25% 17% EMS agencies describe strong early Congestive heart failure 37% 25% 30% successes in reducing reliance on Substance abuse/alcoholism 26% 20% 35%

911 and emergency departments Hospice/terminal illness 26% 19% 44% With the majority of programs in operation for a year or less, it’s not [ MIH-CP Programs Report Lowered Costs for Various Patient Groups. ] surprising that one in four respondents Lowered Too Soon Not say that it’s too soon to tell how much Costs To Tell Applicable success they are having in key areas Frequent 911 users 51% 29% 14% such as reducing costs, reliance on 911, COPD, asthma, diabetes 42% 33% 21% the emergency department and 30-day readmissions. Yet a sizable percentage say Congestive heart failure 33% 33% 28% they are seeing success in a variety of areas. Substance abuse/alcoholism 18% 31% 32% 54% Rate their program as highly or Hospice/terminal illness 18% 29% 41% somewhat successful in showing cost savings for a defined group of patients 60% Rate their program as highly or Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): somewhat successful in reducing 911 A National Survey utilization among specific patient groups CASE STUDY

or nurse practitioner, and eventually, only Colorado Springs EMTs and paramedics. Three in four have mental Fire Department health issues Over a one-year period, the teams Partnering with hospitals, Medicaid care visited 200 homes. Their analysis showed coordination organization to reduce 911 calls that three in four (77 percent) patients had mental health issues, often with other With medical 911 calls increasing by cost of the physician time, while a Kaiser chronic medical conditions. about 8 percent annually and data showing Permanente grant covered data analysis. Calling their program CARES (Community that about 50 percent of 911 responses are “We told them to look, listen and Assistance Referral and Education Services), for non-urgent situations, Colorado Springs connect,” says Jefferson Martin, Colorado a name coined by Battalion Chief Mitch Fire Department, which answers 60,000 Springs Fire Department’s community and Snyder of Kent Fire Department in calls annually, wanted to find ways to public health administrator. “We quickly Washington, they launched a program in redirect some of those callers to resources came to the determination that there was which EMTs and paramedics would continue other than the emergency department. nothing acute medically that we needed the home visits, providing assistance with As a first step, in 2012, the fire to do during those visits.” Instead, patients education and navigating patients to mental department, in partnership with needed education about managing health or other community resources. University of Colorado Health-Memorial chronic diseases, lacked transportation “This is about delivering the right Hospital and Centura Health System’s to pharmacies or doctor’s offices, or care, at the right time, in the right place,” Penrose-St. Francis Hospital, set were in need of resources to assist with says Dr. Robin Johnson, an emergency out to study the reasons underlying psychosocial or economic issues. “The physician at Memorial Hospital who has the overuse of 911 and emergency easy button was 911. That system couldn’t since become a deputy medical director departments. Teams made up of a turn them away,” he says. for CARES. “It is never about saying no physician and an EMT or paramedic went Three months into their investigation, to care, but about redirecting to the best into the homes of frequent 911 users they determined that a physician wasn’t healthcare for the patient.” to assess the patient and their home needed for the assessments. Instead, they With funding from Penrose-St. Francis environment. The hospitals covered the sent an EMT or paramedic with a nurse Hospital, the fire department hired a licensed clinical social worker/behavioral health specialist to provide guidance and case management. The fire department also shifted the responsibilities of a nurse practitioner, already on staff as the fire department’s quality assurance officer, to assist. “In EMS, we are fixers,” Martin says. “We don’t think in terms of long-term behavioral modification, so it’s great to have an expert to come in and help us. One thing we’ve been taught by the behavioral health specialist is that we don’t want to enable or reward negative behaviors, so we are not supposed to do everything for patients. Instead, we set health goals that include steps they can take, and steps we can do for them. IMAGE PROVIDED BY COLORADO SPRINGS FD Our patients may have 10 issues that are contributing to the way they are accessing the system, but we try not to overwhelm

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them. We have to prioritize.” agree to work together to improve care with a nurse practitioner who respond to Patients are seen at home up to five coordination for Medicaid patients. The low-acuity (Alpha or Bravo) calls, and a times. They are also given the phone RCCO pays the fire department $1,000 per Community Response Team, which includes number for a mental health crisis line patient for a 90-day intervention, with a a paramedic, behavioral health clinician that’s answered 24-7, and a number for total of $100,000 budgeted, and also covers and law enforcement officer who respond non-urgent problems, which goes directly the cost of a pharmacist to assist with to 911 calls that are psychiatric in nature. to voice mail. There’s a reason behind not medication reconciliation. The state Office of Behavioral Health having a live person answering those calls, A pilot involving 13 patients found a 75 provided funding, while the medical Martin says. “Our behavioral health clinician percent decrease in hospital readmissions directors of the fire department, emergency has said we need to teach them how to plan during the three months post-intervention, department and a psychiatric facility worked ahead. The lesson is, ‘We will still help you, an estimated cost savings of $145,000 in together to develop protocols that enable but not in 8 minutes or less’,” he says. Medicaid claims, says Kelley Vivian, the the team to do the exam, blood draws and In 2013, the CARES program saw 200 RCCO’s community strategies director. toxicology screening necessary to medically patients. In 2014, they upped that to 500 “The CARES program is a wonderful way clear patients in the field, without needing patients – and are seeing results. Among to interact with our clients that we refer to transport to an emergency department. two-thirds of patients, 911 use dropped by as super-utilizers – the well-known faces in Launched Dec. 1, 2014, the first call came in 50 percent. the 911 system, the emergency department 8 minutes later, Martin says. Other additions to the program include one full-time and three part-time nurse “We think this is a really great way of bringing hospitals, navigators, whose salaries are paid emergency services, a payer source and others together to for through a combination of the fire address community needs, and that there will be payers in department budget; grants from Aspen Point, a behavioral health organization, addition to Medicaid that will be interested in this.” and Kaiser Permanente. – Kelley Vivian, Community Strategies Director, With so many healthcare and community Colorado Medicaid Regional Care Collaborative Organization entities seeing value in the CARES program, the RCCO, Vivian says, is considering The other third have been harder and even in their doctor’s office,” Vivian increased funding for CARES next year. to reach, he says. “These patients are says. “These are patients that need that “We think there are more clients who incredibly complex. For them it’s not about extra level of interaction, to help them can be served. Firefighters are trusted, access to primary care, or education, or become more proactive in their health and thorough and they do a good job of transport. Those are issues we can solve,” so they can take better care of their health.” explaining what is going on in the home he says. “The patients we’ve been less back into the system of care,” Vivian says. successful in moving the needle on are those Program expands to include “We think this is a really great way of with medical, behavioral, mental health and other teams bringing hospitals, emergency services, substance abuse issues.” As a last resort, The next step for the fire department a payer source and others together to the CARES team will enlist the help of the was expanding the program to include two address community needs, and that there legal system, including law enforcement and additional units – a mobile urgent care unit, will be payers in addition to Medicaid that the court system, to compel a psychiatric which includes a paramedic or EMT paired will be interested in this.” evaluation or commitment.

Medicaid Regional Care Colorado Springs Fire Department’s tips for success Collaborative gets involved 1 Conduct a thorough community needs assessment, for your own information Seeking a strategy to reduce costs and to present to partners. “Anecdotes are not enough,” Martin says. among frequent emergency department 2 Collaborate and seek guidance from pharmacists, licensed clinical social workers/behavior specialists and other healthcare specialties. users, the next organization to get involved with the CARES program was the Colorado Medicaid Regional Care Collaborative Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): Organization, or RCCO, a non-profit made A National Survey up of multiple area healthcare entities that Lessons Learned – Tips from the experts

One of the most revealing questions 2 Do a community needs/gap 5 Integrate. Integration with the in the survey relates to lessons learned analysis. Prior to launch, learn the existing healthcare system includes the and advice respondents offered to other resources that are available within the gap and resource analysis highlighted EMS agencies seeking to launch MIH- community, determine where there are above, as well as other integrations in CP programs. The answers of the 86 gaps and find out if your EMS agency can health information technology, referral respondents who offered their input can have a role in filling those gaps. processes and patient navigation to the be summarized in seven themes. “As every community is different, the most appropriate care. most important component of program 1 Collaborate, don’t compete. “We work closely with patient navigation MIH-CP programs work in partnership with development is focusing on the specific to address non-medical, access, insurance, other healthcare stakeholders to fill gaps needs of the population served and behavioral health and social needs.” designing a program around them.” – Survey respondent in healthcare delivery, not replace services – Survey respondent already available within the community. “Develop the network of resources you The most oft-cited recommendation “Although various programs may have will need for the patients enrolled in the was to involve stakeholders early in the common principles, the key to success program.” – Survey respondent is creating one that’s right for your planning process. community’s needs.” – Survey respondent 6 Collect Data. Another common “Early identification of stakeholders is theme was encouraging MIH-CP essential … make sure they are at the table 3 Start small and build on success. programs to collect data relevant to from the beginning.” – Survey respondent Another common piece of advice was to measuring patient outcomes, patient “Develop a community stakeholders list and start with a limited number of patients experience and impact on patient costs. begin to have regular informative meetings.” and build upon experience. Several Some emphasized the need to integrate – Survey respondent also urged EMS agencies to avoid trying with local, regional or state electronic to address all needs simultaneously. The purpose of early stakeholder health information exchanges (HIE). They also encouraged patience and consultation is to inform potential “Join or create local HIE and share your perseverance, saying that getting partners about MIH-CP, to share data and interpret its significance for programs up and running always seems to agency plans, to ensure the regulatory your patients, your system and primary take longer than planned. environment is understood at the outset, healthcare and services providers.” – Survey respondent to allay fears of competition and to secure 4 Focus on the patient. Several buy-in, according to respondents. respondents reminded EMS agencies to 7 Learn from other MIH-CP “Help stakeholders see that EMS is above all, keep the patient at the center of programs. Multiple respondents also committed to better outcomes of population the program design. recommended consulting with established health and better stewardship of healthcare “Always view this type of initiative in light of MIH-CP programs. dollars.” – Survey respondent what is best for the patient, your community “Do not reinvent the wheel. There are a lot “Rather than view EMS as merely the and then your organization. The incentives of resources available to study and emulate. ‘ambulance drivers’ that deluge a hospital, to begin these programs shouldn’t be money Replicate best practices and learn from the EMS should be seen as the critical link that as a primary factor. Collaborate, innovate, agencies that have been running programs is driving the dissolution of barriers to execute, retool, re-execute.” to help avoid potholes.” – Survey respondent coordinated care.” – Survey respondent – Survey respondent

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Conclusion: What Will It Take for MIH-CP to Become a Success?

The growing movement to compel more efficient healthcare spending and the widely acknowledged need for integration and collaboration to solve complex patient issues represents an enormous opportunity for EMS to cement its future in a changing healthcare world. This survey shows that through MIH-CP, many agencies are proactively redefining the role of EMS, from one associated mainly with emergency response to one involved with prevention, patient factors such as whether an MIH-CP program education and effective navigation. This is revenue generating or self-sustaining; is no small feat, given obstacles such as how the program impacts the EMS agency’s opposition from other healthcare entities; relationships and reputation within the confusing and sometimes prohibitive community; whether MIH-CP provides legislative or regulatory barriers; and opportunities for professional growth for limited reimbursement. the EMS workforce; and the extent to which Those obstacles are perhaps one MIH-CP enables the agency to achieve its reason why, out of an estimated 17,000 mission of serving its community. EMS agencies nationwide, only 100 or A third way to look at success is at so have launched MIH-CP programs. And the macro level – that is, to what extent many of those agencies, despite their can MIH-CP impact patient outcomes enthusiasm and strong belief that they are and achieve sustainability on a large doing what’s right for their communities scale, nationwide? Although answering and their patients, admit their long-term that question is premature, what can be sustainability is by no means guaranteed. discussed are the key factors that will contribute to the ability of MIH-CP programs Through MIH-CP, many How to define success? to become firmly established as cost- Defining “success” for a healthcare effective, value-added healthcare service agencies are proactively program such as MIH-CP can be considered providers in the months and years to come. redefining the role of EMS, from multiple angles. For individual patients from one associated mainly or groups of patients, success is defined Three key factors with emergency response to by impact and costs, and measuring it is 1 State level statutory and regulatory one involved with prevention, dependent on collecting and analyzing the change – Today, many state laws and patient education and sort of clinical and outcomes data discussed regulations expressly limit EMS agencies to earlier in this summary analysis. emergency or 911 response and limit their effective navigation. Success can also be considered from the activities to providing medical care only at EMS agency perspective, and could include the scene of an emergency.

Mobile Integrated Healthcare and Community Paramedicine (MIH-CP): A National Survey Conclusion: What Will It Take for MIH-CP to Become a Success?

In practice, EMS practitioners know 3 Reimbursement reform – Today, many 911 calls are not life threatening, and EMS is paid via a transportation-based, instead are patients who could be better fee-for-service model, specifically for served by less expensive resources, such delivering patients to an emergency as primary or urgent care. Moreover, the department. “This provides a MIH-CP should be included narrow view of EMS as emergency-only disincentive for EMS agencies to work in healthcare policy change represents an outdated, siloed view of the to reduce avoidable visits to emergency and reimbursement reform provision of patient care that is rapidly departments, limits the role of prehospital falling by the wayside elsewhere in the that transition EMS into a care in the US health system, is not healthcare system. The findings of this responsive to patients’ needs, and general value-based health services survey, along with the case studies, suggest downstream healthcare costs,” wrote Dr. provider that is adequately that the narrow view of EMS is beginning to Kevin Munjal in a Feb. 20, 2013 JAMA funded to continue its vital change among other healthcare providers editorial. “Financial and delivery model role in safeguarding the as well. reforms that address EMS payment policy health and well-being of our 2 Data proving value – The most may allow out-of-hospital care systems to nation’s population. powerful case for convincing payers or deliver higher-quality, patient-centered, healthcare partners to invest in MIH- coordinated healthcare that could improve CP programs is to provide proof that the public health and lower costs.” the programs achieve the Triple Aim of Hospitals, physicians, and other improved patient experience of care, medical providers are increasingly subject improved population health and reduced to value-based reimbursement, including per capita cost of care. receiving penalties for unnecessary Some MIH-CP programs have already hospital readmissions. Thus far, EMS secured contracts with hospitals, home hasn’t had its reimbursement tied to health, hospice, nursing homes, Medicaid performance or outcomes measures, but care coordination and managed care it’s only a matter of time before CMS and organizations, and even a state department private insurers will expect EMS to fall in of behavioral health. But to turn that trickle line with the rest of healthcare. into a flood, EMS agencies need to engage Individual EMS agency contracts in collecting, analyzing and reporting data. with hospitals and other healthcare In a positive sign, many MIH-CP programs partners will continue to be an important say they collect data and are showing source of revenue to support MIH-CP positive results. Yet there are almost no programs. But MIH-CP should also be peer-viewed, published studies on MIH-CP included in healthcare policy change and outcomes. In addition, the EMS profession is reimbursement reform that transition EMS still working toward a consensus on the best into a value-based health services provider method for demonstrating value, including that is adequately funded to continue its determining what to collect, how to report it vital role in safeguarding the health and and to whom. well-being of our nation’s population.

IMAGE PROVIDED BY MEDSTAR MOBILE HEALTHCARE

30 Transforming healthcare – from hospital to home

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