News & Updates

This is potentially a driver of the “EMS Transformation” to being more than just a means of conveyance to a hospital, as EMS agencies become more of a default healthcare safety net provider in communities facing that may be facing fewer healthcare resources.

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Hospitals shut at 30-a-year pace in U.S., with no end in sight

The next year to 18 months should see an increase in shut downs, with the risks coming following years of mergers and acquisitions.

http://www.chicagobusiness.com/health-care/hospitals-shut-30-year-pace-us-no-end-sight

(Bloomberg)—Industry M&A may be no savior as the pace of hospital closures, particularly in hard-to-reach rural areas, seems poised to accelerate.

Hospitals have been closing at a rate of about 30 a year, according to the American Hospital Association, and patients living far from major cities may be left with even fewer hospital choices as insurers push them toward online providers like Teladoc Inc. and clinics such as CVS Health Corp’s MinuteClinic.

Morgan Stanley analysts led by Vikram Malhotra looked at data from roughly 6,000 U.S. private and public hospitals and concluded eight percent are at risk of closing; another 10 percent are considered “weak." The firm defined weak hospitals based on criteria for margins for earnings before interest and other items, occupancy and revenue. The “at risk” group was defined by capital expenditures and efficiency. among others.

The next year to 18 months should see an increase in shut downs, Malhotra said in a phone interview.

The risks are coming following years of mergers and acquisitions. The most recent deal saw Apollo Global Management LLC swallowing rural hospital chain LifePoint Health Inc. for $5.6 billion last month. Apollo declined to comment on the deal; LifePoint has until Aug. 22 to solicit other offers. Consolidation among other health-care players, such as CVS’s planned takeover of insurer Aetna Inc., could also pressure hospitals as payers push patients toward outpatient services.

There are already a lot of hospitals with high negative margins, consultancy Veda Partners health care policy analyst Spencer Perlman said, and that’s going to become unsustainable. Rural hospitals with a smaller footprint may have less room to negotiate rates with managed care companies and are often hobbled by more older and poorer patients.

Also wearing away at margins are technological improvements that allow patients to get more surgeries and imaging done outside of the hospital.

They “are getting eaten alive from these market trends,” Perlman cautioned.

Future M&A options could be too late—buyers may hesitate as debt laden facilities like Community Health Systems Inc. and Tenet Healthcare Corp. focus on selling underperforming sites to reduce leverage, Morgan Stanley’s Zachary Sopcak said.

The light at the end of the tunnel is some hospitals are rising to the occasion, Perlman said. Some acute care facilities are restructuring as outpatient emergency clinics with free-standing emergency departments. “Microhospitals,” or facilities with ten beds or less, are another trend that may hold promise.

The Acute Community Care Program uses paramedics to provide in-home urgent care after regular business hours, aiming to prevent unnecessary emergency department visits.

Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III, NRP; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS, NRP; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD

Am J Manag Care. 2018;24(9)

https://www.ajmc.com/journals/issue/2018/2018-vol24-n9/early-experiences-with-the-acute-community-care-program-in-eastern-massachusetts

PDF of the full report available here.

ABSTRACT

Objectives: Emergency departments (EDs) frequently provide care for non-emergent health conditions outside of usual physician office hours. A nonprofit, fully integrated health insurer/care delivery system that enrolls socioeconomically disadvantaged adults with complex health needs partnered with an ambulance service provider to offer after-hours urgent care by specially trained and equipped paramedics in patients’ residences. The Massachusetts Department of Public Health gave this initiative, the Acute Community Care Program (ACCP), a Special Project Waiver. We report results from its first 2 years of operation.

Conclusions: This study using observational data provides preliminary evidence suggesting that ACCP might offer an alternative to EDs for after-hours urgent care. More rigorous evaluation is required to assess ACCP’s effectiveness.

Takeaway Points
The Acute Community Care Program (ACCP) is a collaboration between a nonprofit, fully integrated health insurer/care delivery system that enrolls socioeconomically disadvantaged adults and an ambulance service provider to offer after-hours urgent care by specially trained and equipped paramedics in patients’ residences. Without ACCP, these patients would typically be sent to emergency departments (EDs).

Early results suggest that: 

• ACCP appears to reduce ED visits for these urgent care patients. 
• No unexpected deaths occurred. 
• At least 90% of patients are willing to receive ACCP care in the future. 
• More research is needed to quantify the effects of ACCP on ED use and patients’ experiences.

Check out this recent American Ambulance Association video featuring Matt Zavadsky of AIMHI member Medstar Mobile Healthcare as well as Rob Lawrence of Paramedics Plus Alameda. Learn how your ambulance service can share patient stories to help tell the true, wholly human story of mobile healthcare.

MedStar Mobile Healthcare CEO Douglas Hooten recently accepted the "2018 Our Driving Concern Texas Employer Traffic Safety Award" from the National Safety Council. See the photo on Facebook!

Huge congratulations to AIMHI member Metropolitan Emergency Medical Services (MEMS) Pulaski County on their selection as the Arkansas Ambulance Association's ALS Service of the Year! 

View the post on Facebook►

By Mihir Zaveri

July 29, 2018

https://www.nytimes.com/2018/07/29/us/black-woman-ambulance-cost-florida.html

Nicole Black got a call around 1:45 a.m. on July 4 that her daughter Crystle Galloway had fallen in the bathroom of her Tampa, Fla., condominium and that something was wrong. 

She had hit her head, Ms. Galloway’s daughter said, and by the time Ms. Black raced from her home two blocks away, she was slumped over the bathtub, foaming at the mouth and her lips were swollen.

Ms. Black called 911. Later that day, Ms. Galloway slipped into a coma. She died five days after.

But weeks later, questions persist about what happened after the 911 call and whether race played a role in how Ms. Black and her daughter were treated. Four emergency medical workers have been placed on paid leave and face a disciplinary hearing on Tuesday.

Ms. Black said that the responders told her she could not afford the $600 ambulance ride to take her daughter to the hospital, and that she was directed by the medics to drive her there on her own. Ms. Black said she believed her family was treated poorly because they are black.

Officials in Hillsborough County, which provided the emergency medical response, disputed her account, denied that race played a role and said Ms. Black herself said she wanted to take her daughter to the hospital.

But officials acknowledged other troubling issues: Nobody took Ms. Galloway’s vitals at the scene; responders failed to get a signed confirmation from Ms. Black that her daughter wouldn’t use the ambulance; and, in a follow-up report, medical workers indicated that they had not arrived at the scene at all that morning.

Mike Merrill, the county administrator, put all four medical workers on paid leave.

Ms. Black on Saturday would not disclose specific medical information about her daughter, but she said she did not believe she would have died if the responders had acted differently.

“I’m devastated,” Ms. Black said. “I feel like my chest has been ripped open.”

At a news conference last week, Mr. Merrill said he deeply regretted “that this has happened, and clearly this is unacceptable.”

“My deepest sympathies to the family, and my deepest apologies for my fire medics not properly performing and caring for this patient,” he said.

On June 27, Ms. Galloway had a cesarean section, giving birth to a boy. Recent news reports have highlighted the high rates of maternal mortalityamong black women. Nationally, they are three to four times as likely to die in pregnancy or childbirth as white women, according to the Centers for Disease Control and Prevention.

Mr. Merrill said on Saturday that he had not received any information that would indicate that race was a factor influencing the medical workers’ actions, or that if they had acted differently, Ms. Galloway would have survived.

The county identified the emergency medical workers as John Morris, 36, a lieutenant; Justin Sweeney, 36, and Andrew Martin, 28, both fire medics; and Cortney Barton, 38, an acting lieutenant. They could not be reached for comment.

In statements released by the county, the responders described helping Ms. Galloway down the stairs of her home and placing her into Ms. Black’s car, but they denied refusing to take her.

“By the time we realized that no information was obtained, the mother had already left the scene,” Lieutenant Morris wrote.

He said that Ms. Black was “adamant” she would take her daughter to the emergency room and that “at no point would I advise against a person being transported by our rescue.”

Derrik Ryan, president of Hillsborough County Firefighters Local 2294, said Ms. Black’s description of what happened was “not factual.” He said that the medical workers did not “talk her out of going to the hospital” and that they did not talk about the cost of the ambulance trip.

Mr. Ryan called the assertion that race played a role in their interactions “totally ridiculous.”

He acknowledged that the medical workers failed to get Ms. Galloway’s vitals and should have gotten Ms. Black to sign a document stating that they would not be taking Ms. Galloway to the hospital. He said that a medical worker mistakenly entered into a report that they didn’t reach Ms. Galloway.

“Did we make minor mistakes on that call? Absolutely,” Mr. Ryan said. “We did not kill that lady and we did not refuse to transport that lady.”

Mr. Merrill said two Hillsborough County sheriff’s deputies who also responded that night had some discussion with Ms. Black about the cost of transporting her daughter to the hospital.

In a statement, a sheriff’s office spokesman said Ms. Black had asked one of the deputies if emergency medical workers would take Ms. Galloway to the hospital and if she would have to pay for the transport. According to the statement, the deputy responded affirmatively to both questions but did not further discuss the ambulance or its cost with Ms. Black.

After Ms. Black filed a complaint, the sheriff’s office conducted a review and “determined no violations of agency policy or standards occurred,” the statement read.

AIMHI leaders gathered at the Pinnacle EMS Conference in Phoenix this week to share experiences and best practices from their high performance systems. 

BY MANDY ROTH  |   JULY 23, 2018

https://www.healthleadersmedia.com/innovation/diminish-copd-readmissions-reducing-barriers-health-home

Community hospital population health initiative reveals many patients don’t use equipment properly at home 

With COPD comprising the second largest reason for 30-day readmissions at Johnston Health in Smithfield, N.C., the 199-bed community hospital system launched a population health initiative that has united forces inside and outside hospital walls to address this chronic and costly disease. The key focus: What barriers exist to keeping patients well at home?

The comprehensive approach involves multiple initiatives, but the “secret sauce,” is a post-discharge, in-home patient visit, says Peter Charvat, MD, vice president and chief medical officer of Johnston Health, an affiliate of UNC Health Care, Chapel Hill, N.C. The on-site appointment is conducted by a paramedic who brings a respiratory therapist (RT) into the encounter via an electronic tablet. The duo explores every aspect of home care. Among their findings:

1. Visits Reveal Improper Use of Home Equipment

The program has homed in on a key problem: even patients who have had COPD for years often are not properly using their inhalers, or oxygen and nebulizing equipment. It’s not unheard of to find equipment stowed in a closet, unused.

1. Medication and Transportation Create Challenges

Other issues include improper use of medication, plus lack of transportation to numerous post-discharge appointments, which might include primary care providers, pulmonary rehabilitation and smoking cessation classes offered by the county.

1. Complexity Creates Chaos

COPD patients have to deal with multiple, disconnected entities and processes, such as complex discharge instructions, durable medical equipment companies, home health services, and possibly skilled nursing facilities.

MULTIDISCIPLINARY APPROACH
Dr. Charvat, a member of HealthLeaders’ Population Health Exchange, brought all these outside entities into the process. The group also included hospitalists and respiratory therapists, as well as representatives from nursing, the emergency department, outpatient rehabilitation and administration. They opened lines of communication and devised a plan for better approach to COPD care.

One unique element: leveraging a partnership with the county EMS system to use their paramedics to conduct home visits. Cost is shared by the health system and the county.

4-STEP PROGRAM
The COPD program included four elements:

1. Multidisciplinary team approach
2. Standardization of practice and a reduction of inappropriate provider variation
3. Patient education
4. Post-discharge patient contact

Post-discharge patient contact included:

• The on-site paramedic/RT tele-visit during week one to review proper use of equipment and medication
• Phone calls during weeks two through four, when possible
• Pulmonary rehabilitation
• Smoking cessation, if applicable

LONG-TERM PERSPECTIVE
In the four months after launching the program, readmissions dropped about 35 percent, then rose, and, in recent months they have fallen below the 17% threshold the team wanted to surpass. Eleven months into the program, overall readmission rates are about even with the previous period, but most patients are being readmitted for reasons other than COPD, Dr. Charvat says.

“I’ve been very clear to our people,” says Dr. Charvat. “this is a thousand-day journey. In our first year, we developed the infrastructure, and we started doing things that we had never done before.” Year two will determine what program elements are successful and year three will result in further development.

“We set out to better manage patients and we have done that,” Dr. Charvat says. “I really believe we’re managing the disease better overall, because in the end, our efforts are really focused on COPD.”

ADDITIONAL BENEFITS
The Johnston Health COPD program also produced additional benefits:

• Using paramedics and RTs eliminates the need to navigate around physicians’ schedules and help reduce their load
   
• Patients without technology, or those who are technology averse, can still participate in the telehealth aspect of the program because paramedics bring the electronic tablet with them and set up the connection with the respiratory therapist. In addition, the service does not require a home Internet connection. 
• The program helped standardize care delivered between inpatient and outpatient RT departments
• The process helped build a connection between the hospital, durable medical equipment providers and skilled nursing facilities

COST AND IMPACT OF COPD

• “COPD is the third leading cause of death in the United States. More than 11 million people have been diagnosed with COPD, but millions more may have the disease without even knowing it,” according to the American Lung Association. “COPD causes serious long-term disability and early death. At this time there is no cure, and the number of people dying from COPD is growing.”

• A study published June 17, 2013, in ClinicoEconomics and Outcomes Research online quantified the financial impact: “In 2010, the cost of COPD in the USA was projected to be approximately US$50 billion, which includes $20 billion in indirect costs and $30 billion in direct health care expenditures.”

Mandy Roth is the innovations editor at HealthLeaders.

The emerging role of emergency medical services in reducing readmissions

by Tammy Leytham

July 1, 2018 

https://www.homecaremag.com/july-2018/community-paramedicine

When Lt. J.D. Postage makes house calls as a community paramedic in Violet Township, Ohio, his goal is to ensure patients stay out of the hospital and have their basic needs met. 

He’s part of the rapidly-evolving field of mobile integrated healthcare or community paramedicine (MIH-CP) finding a foothold in metropolitan areas as well as in rural communities. Goals range from reducing the number of hospital readmissions to keeping patients out of emergency rooms to signing up residents for Meals on Wheels.

When it comes to community paramedicine, a one-size-fits-all mentality just doesn’t fit.

Reducing Readmissions

For some patients, follow-up instructions after hospital visits can be a daunting task. Add to that issues with being low-income, and many patients end up right back in the hospital with more medical issues.

Climbing health care costs have led many EMS providers to put this new tool in their medical chest. Avoidable hospital readmissions cost an estimated $40 billion a year, according to a Department of Health and Human Services (HHS) report.

Heart failure readmission rates nationwide are more than 20 percent for cardiac patients, according to data published in 2017.

The Hospital Readmissions Reduction Program, mandated by the Affordable Care Act (ACA), gave an extra incentive to providers to cut those numbers. It requires the Centers for Medicare & Medicaid Services (CMS) to reduce payments to hospitals with excessive readmissions. Recent studies show readmission rates have declined since the program began, according to a CMS spokesperson.

But lowering re-admission rates is not the only goal for MIH-CP programs

“It’s across the board in terms of what departments are doing,” said Scioto Township Fire Chief Porter R. Welch. As chair of the Ohio Fire Chiefs’ Association MIH-CP Committee, Welch helped draft and adopt legislation that permitted community paramedicine in Ohio.

“It’s really based on the needs of the community,” said Postage, the only community paramedic on staff at Violet Township.

In 2016, Mount Carmel Health collaborated with first responders in four departments (soon to be five) to implement the community paramedicine program in central Ohio.

It started with heart patients, working to see what the triggers were causing them to go back to the hospital. “What are the common themes,” Postage said. “Are they taking medications right? Do they understand the diet?”

Now, Postage has developed resources throughout the community to provide whatever the patient needs. “I get referrals from apartment complexes, from the food pantry, from guys at the fire station, from doctors’ offices,” he said.

Providing Social Services

Churches are also on the front lines in providing volunteers and financial assistance for patients who need it. One church donates medical supplies.  In Delaware, Ohio, “they’re doing something a little different,” Welch said.

With no official community paramedic, EMS responders there take note when an elderly patient needs Meals on Wheels, help obtaining and taking medication, or transportation to doctors’ appointments. In those cases, a county-funded senior citizen program has an on-staff liaison who makes contacts and gets the patient in touch with proper services.

It’s the same approach taken at Welch’s department in Scioto Township. “It’s filling the gap in terms of what the community needs, and every community is different,” he said.

The biggest hurdle his department faces is “making sure we’re putting these folks in touch with the right social services.”

Birmingham Fire & Rescue Service in Alabama works with local hospital systems and community resources through its Community Assistance Referrals and Education Services (C.A.R.E.S.) program, started in February 2016.

It began with scheduled home visits conducted with frequent 911 users, said Lt. Ben Thompson, one of two EMTs assigned to the program. “From there, we integrated ourselves in the greater health care community.”

Responders found a “multitude of issues being faced by our citizens upon returning home from the hospital,” Thompson said. “The harsh reality is that many in Birmingham are living far below the poverty line. For these folks, the problems never stop.”

So, it is difficult, if not impossible, to properly follow through with their discharge instructions. “What we do is try and coach them along so they don’t get sick again,” he said. It can be a task as simple as calling their doctor to schedule an appointment.

“Sometimes, they just enjoy having someone coming in to check on them,” Thompson said. “Everyone likes to feel important. Many of these people rarely have had that opportunity. So, if anything, this is our goal: To let every Birmingham citizen know that they are important and their health matters. Sometimes that’s all they need.”

Similar community paramedicine programs have taken root and expanded across the country, treating and keeping patients in their home by having EMS personnel visit patients in a non-emergent situation. Responders provide post-hospital follow-up visits, chronic disease management, preventive care, non-emergency evaluations, lab work, wound checks, cardiac checks and in-home safety risk assessments.

Care Around the Nation

The Mayo Regional Hospital Emergency Medical Services in Dover-Foxcroft, Maine, launched its community paramedicine program this past May, as did Haywood County with the Haywood Regional Medical Center in Clyde, North Carolina.

The Albuquerque, New Mexico, Fire Department started its community paramedicine program in April. Last fall, Wisconsin Gov. Scott Walker signed legislation allowing its EMS responders to make non-emergency house calls.

Climbing health care costs have led many EMS providers to put this new tool in their medical chest. Avoidable hospital readmissions cost an estimated $40 billion a year, according to a Department of Health and Human Services (HHS) report.

Haywood Regional Medical Center sees a paramedicine program as a way to cut down hospital readmissions that are reimbursed at a lower rate by Medicare, Medicaid and insurance programs, The Mountaineer newspaper reported. Haywood County emergency officials also want to cut down on the number of calls from those who repeatedly use EMS for non-emergency situations.

In Bergen County, New Jersey, Valley Health Systems has seen more than 950 patients in their homes since launching its MIH in 2014, said Christina Pratti, RN and clinical coordinator. Their program works hand-in-hand with providers and the hospital to extend this home-style option of EMS, specifically for cardiac patients.

The team works with Valley Home Care and focuses on patients who refuse or don’t qualify for homecare services in order to fill in the gaps in care. And it’s working.

Pratti said her team’s ability to administer things like Lasix via IV at home while communicating with a patient’s primary care doctor has reduced the number of hospital visits and re-admits for congestive heart failure.

Funding Concerns

Funding for MIH-CP programs is as varied as the way programs are administered.

“There’s not a lot of consistent funding,” Welch said of the Ohio programs. In Delaware, Ohio, for example, the liaison is funded by a county senior citizen group.

Postage’s position is paid for by the Violet Township Fire and EMS Department, though they have a contract with Mount Carmel Health for some high-risk patients.

“Pretty much, the fire department foots the bill,” Postage said. “There’s no structure for patients to pay for the services so pretty much everything I do is free to the public.”

Birmingham C.A.R.E.S. took a big step forward recently when it negotiated a contract with UAB Hospital to conduct follow-up home visits on frequent Emergency Department users. C.A.R.E.S. will be compensated by the hospital for carrying out these home visits, Thompson said.

“We also have another large hospital system in negotiations to do the same for their patients,” he said. “The compensation piece was a huge achievement because now we can actually self-sustain our efforts. From what I know, we are the first in the state to negotiate such a contract.”

While it’s just a two-man shop for now, the department has plans to add personnel as the patient pool grows, Thompson said.

Community paramedics in Ohio go through additional training and 232 hours of clinicals, Postage said. “My program is mirrored through several other fire departments. We all work together,” he said.

Mount Carmel Health works with those departments in obtaining clinicals. A new program is being launched on stroke follow-ups.

“With each program we roll out, we do additional training,” Postage said.

This is notable for a couple of reasons….

1. This clearly articulates Value-Based Transformation and Innovation as one of Azar’s 4 priorities.
2. Congressional representatives and their staffers have told us that CMMI has the authorization to change payment policy, without Congressional action.
3. Some EMS representatives have already met with Mr. Boehler promoting alternate economic models for EMS.

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HHS Secretary Azar Announces Senior Advisor for Fourth Departmental Priority

https://www.hhs.gov/about/leadership/secretary/priorities/index.html

On Wednesday, Health and Human Services Secretary Alex Azar announced that Adam Boehler, currently Director of the Center for Medicare & Medicaid Innovation (CMMI), will also begin serving as Senior Advisor for Value-Based Transformation and Innovation 

Boehler is the fourth individual Azar has appointed to serve as a senior advisor to the secretary overseeing one of his four key departmental priorities, following the naming of Jim Parker as Senior Advisor to the Secretary for Health Reform and Director of the Office of Health Reform, Dan Best as Senior Advisor for Drug Pricing Reform, and Dr. Brett Giroir as Senior Advisor for Opioid and Mental Health Policy.

“Adam is the kind of results-oriented, transformational leader we need to deliver on what President Trump has promised the American people: better healthcare at a lower cost,” said Secretary Azar. “At CMMI, he has already demonstrated an ambition for bold change, and will now be able to bring his deep experience with private sector innovation to help HHS execute on the long-talked-about goal of transforming our healthcare system into one that pays for value.”

Since April, Boehler has served as Deputy Administrator and Director of the Center for Medicare & Medicaid Innovation. Boehler is the former CEO and founder of Landmark Health, a company focused on delivering medical services to the most chronically ill patients. Boehler is also the founder of Avalon Health Solutions, a leading provider of laboratory benefit management services in the country. Additionally, Boehler was an Operating Partner at Francisco Partners a leading global private equity firm focused on healthcare technology and services investing.

The senior advisers will help advance the four initiatives Secretary Azar has identified for his transformation agenda: combating the opioid crisis; bringing down the high cost of prescription drugs; addressing the cost and availability of health insurance; and transforming our healthcare system to a value-based system.