Transcript MIH NCAEMSA 4-17 Abridged - North Carolina Association of

Mobile Integrated Healthcare
Erick Beck, D.O., MPH, NREMT-P
Associate Chief Medical Officer
AMR & Evolution Health - Envision Healthcare
Session Goals
• Update on Current MIH Programs in the U.S.
• Results of NAEMT/JNEMSF MIH-CP Survey
“Mobile Integrated Healthcare is an
innovative and patient-centered
approach to meeting the needs of
patients and their families. The model
does require you to “flip” your thinking
about almost everything – from roles for
health care providers, to what an EMT or
paramedic might do to care for a patient in
their home, to how we will get paid for
care in the future.
The authors teach us how to flip our
thinking about using home visits to assess
safety and health. They encourage us to
segment patients and design new ways to
relate to and support these patients. And
they urge us to use all of the assets in a
community to get to better care. This is our
shared professional challenge, and it will
take new models, new relationships, and
new skills. “
Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
MIH-CP Program Updates
Dallas Fire-Rescue to offer home health care checkups
By TRISTAN HALLMAN
18 November 2013
Most doctors don’t make house calls anymore. But some Dallas-Fire Rescue
paramedics soon will. A pilot program starting next year calls for paramedics to visit
the homes of frequent 911 callers.
The idea behind the Mobile Community Healthcare Program is to try to prevent and
reduce health emergencies, officials said Monday at a Dallas City Council public safety
committee hearing.
Assistant Fire Chief Norman Seals, who oversees the EMS bureau, told members of the
City Council’s Public Safety Committee that he was “really fired up” about the
program. He said he hopes to expand it as he restructures some EMS services.
The plan drew praise from committee members.
“This is a fantastic program,” council member Sandy Greyson said. “This is what
we’ve been needing for a long time. This is the way to go. … This is really the future.”
Firefighter, nurse practitioner team
up for 'urgent care on wheels'
Jan 23, 2013 - MESA, Ariz. - The Mesa Fire Department is getting some
national attention for a program that started back in August. It's an idea
that may be helping with overcrowded emergency rooms.
For the past six months, a Mesa Fire Captain has been teamed up with a
nurse practitioner to respond to low-level emergencies.
Mesa Fire/Medical teamed up with Mountain Vista Hospital, pairing up
Fire Captain Brent Burgett and nurse practitioner Tom Morris to respond
to low-level emergencies.
Green Bay Hospital Enlists
Fire Department To Visit
Patients At Home
April 29, 2013
Bellin Health, a major healthcare provider in northeastern Wisconsin, is
teaming up with the Green Bay fire department to check up on patients.
Bellin Hospital is paying the city $50 each time firefighters are
dispatched at Bellin’s request to make house calls on discharged
patients.
As a bonus, she says, firefighters found a problem with a smoke
detector in one patient’s house.
Ontario Expanding Community Role for Paramedics
Community Paramedicine Programs Improving Access to Care for
Seniors
January 21, 2014
“Ontario is supporting the expansion of community
paramedicine programs to improve access to home care
and community support services for seniors and other
patients with chronic conditions.
The province is investing $6 million to support the
expansion and development of community paramedicine
initiatives across the province. These programs allow
paramedics to apply their training and skills beyond the
traditional role of emergency response…”
“Community Paramedicine programs help
patients get the care they need in their
communities, while reducing unnecessary
emergency room visits and hospital admissions.
These new supports for community
paramedicine will also help seniors and patients
with chronic conditions manage their conditions
better and stay healthy.”
Deb Matthews
Minister of Health and Long-Term Care
Wake County, NC
(Wake County EMS)
• Program Goals & Methods:
– Respond
• High acuity, low frequency calls
• High-risk AMA’s (20 resource and ? Follow-up)
– Reduce
• Low acuity, high frequency calls
• SNF falls
– Redirect
• Substance Abuse / Mental Health
• Funding:
– Self funded
Wake County, NC
(Wake County EMS)
• Outcomes - 2013
– Respond:
• Overall SCA survival of 14%
• 90% neurologically intact
• Shockable rhythms = 38%
– With a 98% neurologically intact survival rate
– Reduce:
• Evaluated over 150 patients
• No adverse outcomes
– Redirect:
• 1,503 patient encounters, 514 (34.2%) met diversion eligibility criteria
• 315 (61.2%)agreed to be transported to WakeBrook instead of the local ED
• Only 4 (1.3%) patients transported to WakeBrook were referred back to the ED,
none of whom subsequently required medical intervention
• 199/315 patients (63.2%; CI95 57.8-68.3) treated and discharged home with mental
health follow-up
• Estimate program saving = 2,448 ED bed hours
• 100 hospitalizations
• Reduced costs of care by $500K
Allegheny County, PA
(Center for Emergency Medicine)
• Program Goals & Methods:
– Improve patient outcomes and experience of care
– Reduce preventable ED visits and hospitalizations
• Primary focus - familiar faces and vulnerable patients
– Regional service delivery model
• Referrals from 45 EMS agencies and 15 hospitals in
Allegheny County (Pittsburgh and surrounding communities)
– Psycho-social assessment by Community Paramedic
• Serves as patient navigator, patient advocate and health
coach to get patient enrolled in applicable social service
agencies
Allegheny County, PA
(Center for Emergency Medicine)
• Outcomes:
– Over 250 patients referred to program since launch in
September, 2013
– One patient with 29 EMS trips to ED prior to our
involvement for uncontrolled hypoglycemia
• Since enrollment, back 1 time for a problem with his fistula.
Estimated savings of $21,000 in avoided EMS trips and ED
costs
• Funding
– Two year, $500,000 grant funded by (very)
competitive integrated delivery systems
Hunt County, TX
(American Medical Response)
• Program Goals & Methods
– Frequent system utilization
• Funding
– Grant funded
• Outcomes
–
–
–
–
Scheduled visits for familiar faces
Telephonic intervention coupled with in-home visits
Average 88.9% reduction in EMS transports
Average 69.2% reduction in emergency department
utilization
– Average 45.4% reduction in hospital admissions
Eagle County, CO
(Eagle County Paramedics)
• Program Goals & Methods:
– Ensure all patients have a medical home
– Reduce re-hospitalizations by 50%
– Enhance injury prevention versus potential costs
associated with no prevention
– Enhance number of vaccinations given and Public
Health visits
• Funding:
– Self funded
Eagle County, CO
(Eagle County Paramedics)
• Program Goals & Methods:
– Single Community Paramedic deployed into rural
community
– Post discharge follow-up
– Primary care follow-up
– School Based Health
– Injury Prevention – Community
– Public Health
– Social Services Adult Protection visits
– In home lab services
– Starting new Mental Health and Substance abuse program
with County and Hospital
Eagle County, CO
(Eagle County Paramedics)
• Outcomes:
– CP Team was part of hospital team that reduced
readmissions in our local hospital last year over
75%
– N=1100 patients that fit criteria Initial Readmit
rate was 4.26% decreased to 1.01%
– Health Care Expenditure Savings per patient visit
$1,279
St. Louis, MO
(Barnes-Jewish / Abbott EMS / AMR)
• Program Goals & Methods
– Targeted readmission reduction
• Funding
– Hospital contract
• Outcomes
– Reduction of CHF, AMI, COPD and pneumonia
admissions
– 10 patients to date
Minneapolis, MN
(North Memorial Medical Center)
• Program Goals & Methods:
– 16 CP's in 3 Primary Clinics in the North Minneapolis
area
•
•
•
•
•
•
12-14 patients per 12 hour shift
Assigned patients by a clinic coordinator
Primary Care focused
Patients need to have a care plan or be in a medical home
Medical home and care plan avoids duplication of service
Focus on patients with chronic disease with a heavy
emphasis on Diabetics
• Assistance with wound management
• All lab work completed on-site
• Tracks frequent ER utilization with follow-up
Minneapolis, MN
(North Memorial Medical Center)
• Outcomes:
– Outcomes continue to be tracked unofficially, with
outcomes subjectively, felt to be very positive.
• Work at the state level to develop a common data base to
show the positive results of using a CP
• Data should be available soon
• Current Health Care Delivery system medical assistance
demo project with 6,000 enrollees has shown an over all
reduction in per member per month cost of medical
assistance patients
• With the reduction gets a shared saving payment to the
healthcare system from managed care and state fee for
service
Minneapolis, MN
(North Memorial Medical Center)
• Program Funding:
– CP’s integrated in a Medicare shared savings ACO
program with 10,000 enrollee’s
– CP’s primarily target the MA population in a state
Health Care Delivery System demo (HSDS) with
6,000 enrollee’s
– Medical assistance covers eligible CP services at
the rate of $60 an hour of the patient is in a
primary care plan or assigned to a medical home
Arlington, TX
(American Medical Response)
• Program Goals & Methods
– Frequent system utilization and readmission reduction
• Funding
– Hospital and City share FTE cost
• Outcomes
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–
–
–
Targeting CHF, COPD and cardiac patients
165 patient census
Average 88.9% reduction in EMS transports
Average 69.2% reduction in emergency department
utilization
– Average 45.4% reduction in hospital admissions
St. Louis, MO
(Christian Hospital EMS)
• Program Goals & Methods:
– Increase Population Health
– Improve patient outcomes and experience of care
– Navigate non-medical emergency patients from using EMS
and ED
– Reduce EMS and ER abuse for non-medical emergencies
– Decrease financial loss in ER and EMS for non-medical
emergencies
– Ambulance and an specially trained paramedic responds to
low-acuity calls
– Patients are triage and receive a medical screen
• If no medical emergency exists we will not transport to the hospital.
We will treat at home, make an appointment to the Health Resource
center or set up appointment with their PCP
St. Louis, MO
(Christian Hospital EMS)
• Outcomes
– Navigated 1100 non-medical emergency patients
away from the ER40 high utilizers from EMS and the
ER
– Decreased EMS and ER volume 11% respectively
– 22% decrease in EMS and ER use with this group since
the 10th of February
• Program Funding
– Awarded $100,000 grant from the hospital
foundation, contracts pending with private payers and
ACO
Reno, NV
(REMSA)
• Program Goals & Methods:
– Improve access to appropriate levels of quality care and
treatment by 40%
– Reduce total patient cost by $10.5 million over three years
for Washoe County 911 acute and non-acute patients.
• 9-1-1 emergency ambulance triage and treatment redesign:
Alternative pathways are provided to patients seeking medical
evaluation of urgent medical conditions.
• Stakeholder and community engagement: New linkages between
the emergency ambulance delivery system and the broader health
care delivery system.
• Aligned financial incentives: Reform of existing payment systems
achieves sustainable funding of patient care services.
Reno, NV
(REMSA)
• Program Funding
– $9.5 million CMMI grant
– New contract with hospital system for Nurse
Advice line
Las Vegas, NV
(American Medical Response)
• Program Goals & Methods
– Frequent system utilization
• Funding
– Self funded
• Outcomes
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–
–
–
Scheduled visits for familiar faces
Medic accompanies patient to PCP appointments
Average 88.9% reduction in EMS transports
Average 69.2% reduction in emergency department
utilization
– Average 45.4% reduction in hospital admissions
Chicago, IL
(MedEx & University of Chicago)
• Program Goals & Methods
– Readmissions reduction
• Funding
– Hospital and home health funded pilot
• Outcomes
–
–
–
–
–
Paramedic transitional care visit in 0-24 hours
HRS Home health partnership for ongoing home care
35 transitional care patients
Enhanced patient experience
Average 89% reduction in hospital admissions for
enrolled patients
Fort Worth, TX
(MedStar Mobile Healthcare)
• Program Goals:
– Reduce preventable 9-1-1 and ED use in High
Utilizer Group (HUG) patients
– Redirect low-acuity 9-1-1 callers to better care
setting
– Reduce preventable 30-day CHF readmissions
Reduce preventable observation admissions
– Reduce Voluntary Hospice Disenrollment
– Reduce ED visits for Home Health patients
Fort Worth, TX
(MedStar Mobile Healthcare)
• Methods:
– MHPs proactively manage patients through education, connection
with patient centered medical homes and 9-1-1 redirection when
appropriate
• Including in-home diuresis if necessary
– RNs use internationally developed and local medical control approved
nurse advice algorithms to help the patient access the most
appropriate care setting for their medical needs
– MHPs receive Obs patients and provide in-home assessments to avoid
Obs Admit
– MHPs respond to registered hospice patients to evaluate and navigate
with assistance of hospice RN
– Home Health patients registered in CAD, MHP response & assess,
coordinate with Home Health RN
• And do night/weekend call for agency
Fort Worth, TX
(MedStar Mobile Healthcare)
• Outcomes:
– HUG - 74 patients with 2-years of data (340 total)- averaging 54% reduction in
9-1-1 or ED use in enrolled patients during enrollment, 83% reduction postgraduation. Patient satisfaction 4.9 out of 5 (5 being most satisfied).
– 9-1-1 Nurse Triage - 1,382 9-1-1 callers referred to RN, 566 (41%) referred to
alternate disposition. Patient satisfaction 4.6 out of 5 (5 being most satisfied)
and 93% stated talking with the nurse helped.
– CHF Readmission - 23 patients enrolled that had a prior 30-day readmit AND
the primary care coordinators believed a readmission was likely. Only 3
patients (13%) had a 30-day readmission. Patient satisfaction 4.9 out of 5 (5
being most satisfied). EuroQol Self-Assessment of Health Status improvement
of 38%
– Obs Admit Prevention - 73 patients enrolled. Only 3 patients (4%) had a
revisit to the ED prior to PCP appointment.
– Hospice Revocation Prevention - 114 patients at-risk for revocation enrolled,
only 12 (11%) revoked.
Fort Worth, TX
(MedStar Mobile Healthcare)
• Program Funding
– Patient enrollment fee from referring agencies; or
– Patient contact fees from referring agencies
– Direct funding from hospitals for 9-1-1 Nurse
Triage
– Per enrolled patient/per month for Hospice
program
NAEMT/JNEMSLF Survey
• To better understand the extent and characteristics
of MIH/CP programs across the country
• To have a basis for understanding the MIH/CP trend
– which helps all of us in EMS – so we can develop
strategies and policies to support it
• Distribution assistance from the JNEMSLF
NAEMT MIH/CP Committee
Representation from…
Survey results at-a-glance
• 3,781 total responses were received
– Total responses were evenly dispersed across all
types of EMS delivery models.
• 232 unique MIH/CP programs were reported
– (6% of responses).
• 566 respondents (15%) indicated that their
EMS agencies were in the process of
developing a MIH/CP program.
Catalyst for starting a MIH/CP program
Gap analysis of health needs
68%
Community assessment
66%
30%
Other CP programs
Other healthcare stakeholders
20%
Other 7%
Combat repeat users
1%
Respondents were able to select more than one response, resulting in a percentage total greater than 100%.
Participants in initial MIH/CP
program assessment
Medical Director
77%
Hospital
77%
44%
Other EMS services
41%
Public health
Home health
21%
Other 7%
Time MIH/CP program
has been in operation
Less than 1 year: 42%
1 – 3 years: 23%
More than 3 years: 35%
MIH/CP program models
66%
Frequent EMS User
46%
Readmission avoidance
Primary care/physician
extender model
See and refer to alternate
destination after assessment
28%
24%
911 Nurse Triage 8%
Who participates in
providing patient care?
94%
Paramedics
54%
EMTs
AEMTs
25%
Nurses
24%
Physicians
21%
Nurse Practitioners
12%
Physician Assistants
12%
MIH/CP practitioners
• Are practitioners paid a higher rate than
traditional roles?
YES : 37%
NO : 63%
• Do practitioners have an advanced scope of
practice?
YES : 11%
NO : 89%
Next Steps
• Conduct follow-up survey of MIH/CP programs
– Drill down a little further to round out info
• Publish results
– Communicate to Stakeholder groups
• MIH/CP Vision Statement
– Endorsed by committee member agency
representatives, plus…
Opportunities in Your Community?
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