Fully a third of all the Medicare beneficiaries transported to a hospital emergency department by an emergency medical services ambulance could have been treated safely in an alternative setting, according to recent studies.
If Medicare beneficiaries with low-acuity needs were taken by EMS to a clinic or doctor’s office instead of an emergency department — or, better yet, treated more comfortably and conveniently at home, if appropriate — an estimated $600 million could be saved annually. If the same patient-centered policy were approved by third-party payers as well, estimated annual savings for the health care system could reach $1.2 billion.
“Discontinuities in health services are commonplace for patients who live at home,” observes Eric Beck, D.O., assistant director of the emergency medical residency program at the University of Chicago Medical Center. “For the chronically ill, the frail elderly and the mobility-impaired, care gaps such as lack of post-acute transitional care make preventable readmissions a virtual inevitability.”
Many single-purpose providers offer niche care for the homebound, Beck notes. But they often have restricted hours of operation. Patients are routinely referred to hospital emergency departments when problems arise outside normal business hours “even though it is common knowledge that the ED is an imprecise match to their needs,” he says.
Meeting in Chicago under the aegis of the American College of Emergency Physicians a little over four years ago, a consortium of 10 EMS-affiliated physicians and health care strategists from around the country, including Beck, proposed a new model for delivery of appropriate, around-the-clock, comprehensive, planned or unplanned care outside the hospital, using interprofessional medical teams.
They called it mobile integrated health care practice, or MIHP. The P has since been dropped as confusing. But as MIH, it’s an idea that is already recording encouraging results.
Reimbursement for ambulance services has been based on the life-support procedures performed and miles driven. But the movement to pay-for-performance rather than fee-for-service throughout the reformed U.S. health care system has changed the focus of EMS as well. The watchword today is "outcomes".
“That doesn’t mean, ‘We get there in eight minutes, 59 seconds, 90 percent of the time,’” said Edward Racht, M.D., chief medical officer of American Medical Response, the nation’s largest private ambulance service, in an interview with the magazine EMS World in 2013. Racht explained that EMS providers were beginning to measure things like improvement in pain management and the survival rate of heart attack victims — which meant redefining what EMS does, and retraining emergency medical technicians and paramedics to take on new roles based on community need.
Indeed, in many American municipalities a new concept has been put into action: community paramedicine. Ambulance crews of technicians operated by private companies and public agencies have been beefed up to include an advanced practice provider — a registered nurse, a paramedic with an additional credential in community paramedicine or a nurse practitioner. They still scramble to answer 911 calls, but they also, depending on state licensure and scope-of-practice regulations, make home visits to instruct patients in the use of drugs or medical devices, draw blood for lab tests, or transport patients with conditions like flu or minor wounds to clinics or urgent care centers rather than to the ED.
In Reno, Nev., for example, most congestive heart failure, chronic obstructive pulmonary disease, post-myocardial infarction and post–cardiac surgery patients discharged from any of three major hospitals are given a direct phone number they can call at any time during the next 30 days to seek the advice of or summon a community paramedic. Reno’s nonprofit Regional Emergency Medical Services Authority also staffs a free, all-day, every-day nurse health line with nurses who’ll answer medical questions from anyone who dials and follow up when appropriate.
Busy local doctors can request a home visit to a patient by a REMSA community paramedic, who’ll evaluate the patient’s condition on-site. And paramedics are empowered to choose the most appropriate point of care for patients, especially for frequent visitors to the ED.
REMSA crews, for example, had transported one indigent, uninsured, panic attack–prone man to a Washoe County emergency department 23 times over a period of just three months in 2013, they reported. Under the new community paramedicine program, REMSA paramedics redirected him, with his consent, to a local clinic. There he reconnected with his primary care physician and was re-enrolled in Medicaid. Over the next 20 months he was seen in the ED only three times — and zero times the following year while keeping his doctor appointments.
Calling central command
“There are lots of examples of local community paramedicine pilots, and they’re doing good work,” acknowledges Beck. “But they face challenges. In larger markets serving multiple communities, scale becomes an issue. As local exercises, with their own features, they may not align with other [players]. And many EMS systems don’t have the budgetary support to employ advanced practice providers.”
A truly comprehensive, accountable mobile integrated health care program, as outlined in the consortium proposal, will have 12 essential features:
- Cataloging of provider competencies and scopes of practice.
- Medical oversight, both in program design and in daily operation.
- Population needs and community health assessment.
- Strategic partnerships with stakeholders, engaging a spectrum of health care providers including, but not limited to physicians, advanced practice nurses, physician assistants, nurses, emergency medical services personnel, social workers, pharmacists, clinical and social care coordinators, community health workers, community paramedics, therapists and dietitians.
- Patient access through a patient-centered mobile infrastructure.
- Coordinating communications, including biometric data.
- Telepresence technology, connecting patients to resources, and permitting consultation between in-home providers and those directing care.
- Capacity for patient navigation.
- Transportation and mobility.
- A shared and integrated health record.
- Financial sustainability.
- Quality and outcomes performance measurement.
A pioneer in designing and partnering MIH programs across the country has been Evolution Health, based in Dallas. It’s a subsidiary of Envision Healthcare, of Greenwood Village, Colo., which is also the parent company of American Medical Response. In addition to his clinical practice in Chicago, Beck is Evolution’s president and CEO.
At the heart of Evolution’s MIH network is a mobile command center in Dallas. Working through this communication hub, cross-trained community MIH teams in nine states last year coordinated at-home integrated acute care, chronic care and prevention services in response to more than 2 million calls, Beck reports. More than half of those patients received a home visit from a team member, he adds. Others were assisted by phone or telemedicine, or were met by a provider at a “pop-up clinic” in a convenient park or coffee shop.
“We’ve created an MIH core curriculum for all the disciplines,” he emphasizes. “Everyone needs to be recalibrated in understanding the roles and capabilities and expertise of the other team members. Everyone takes the same course.”
EMS — the focal resource
While operating as multiagency community partnerships often led by hospitals or health systems (examples include Beck’s University of Chicago Medicine, Barnes-Jewish Hospital in St. Louis and Banner University Medical Center in Tucson, Ariz.), at the core of most MIH programs is the local EMS provider (examples include American Medical Response in Arlington, Texas, MedStar Mobile Healthcare in Fort Worth, Texas, and Wake County EMS in Raleigh, N.C.). The EMS agency is an ideal focal resource, Beck explains, because virtually every community has one, it’s linked to all levels of care through its 24/7 capability for mobility and readiness, and its workforce is already expert in planning, coordination and communications.
Moreover, he points out, EMS systems possess a capital-intensive, difficult-to-replicate readiness infrastructure ideally suited to MIH. EMS providers already have vehicle fleets, robust voice and data communications systems and electronic health record systems, and have portable biometric and sophisticated treatment equipment on board. And since much of this infrastructure comes with the redundancies and excess capacity essential to emergency preparedness, EMS systems are well-suited to absorb the additional loads arising from the new mobile health strategy with minimal marginal cost. (Since 2014, Evolution MIH partners have been reimbursed through a bundled payment structure agreed to by cooperating health insurers, Beck notes.)
“When linked with request-for-service information from dispatch systems, geographic information systems and population health data, the existing EMS infrastructure provides a powerful tool for launching and supporting an MIH program,” Beck suggests.
At Banner University Medical Center in Tucson, readmissions for participating Medicare Part B patients have been reduced by more than half through intensive follow-up by MIH nurse practitioners and case managers, reports Phillip Factor, D.O., professor of medicine and neurology at the University of Arizona College of Medicine. In fact, the readmission rate for those patients now stands at less than 6 percent.
“It makes a big difference for the patients to have an advanced practice provider go to their home after they’ve been discharged and look around,” he says. “In almost all cases, something’s not right. Patients are given a number to call if they have problems, and we have a multi-triage system to decide whether they can wait or need an ambulance immediately. Their discharge summary lists the physician who’s responsible and, if appropriate, that’s where we take them."
Says Beck: “Some hospitals are trying to manage the present. They’re caught up in working their way through the challenges of the near term. Others have a strategy that’s more outward looking. They’re pursuing value-focused care. For them, mobile integrated health is coming into focus pretty quickly. It’s a new iteration of a familiar set of players ... and a pretty exciting new set of menu choices for hospitals and health systems that are thinking holistically.”
David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.
The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.