News & Updates

Mount Sinai Health System’s St. Luke’s Hospital has been looking for a way to decrease readmissions among its recently discharged heart failure Medicaid patients.

The hospital’s 30-day readmission rate of 20% to 25% among such patients was comparable to national statistics within national averages. But a growing Medicaid patient population in New York’s Harlem neighborhood coupled with a systemwide push to incorporate more population health strategies within its clinical settings led to a search for a better way to help heart failure patients manage their conditions outside of the hospital.

“It was a good and important time to make sure that we were integrating some of these social need interventions as well as connection to the community in really trying to address root causes,” said Dr. Theresa Soriano, senior vice president of care transitions and population health at St. Luke’s.

That was the impetus behind St. Luke’s pilot program launched in July aimed at reducing hospital readmissions among Medicaid beneficiaries with congestive heart failure by educating patients how to better self-manage their conditions at home.

The program will provide individualized health coaching to 100 Medicaid beneficiaries in three adjacent city neighborhoods: Harlem, the Upper West Side and Washington Heights. Community health workers trained by nurse specialists on St. Luke’s cardiac-care team will provide individualized coaching to patients on the health issues and warning signs related to heart failure, such as the importance of checking weight and limiting fluid intake.

The one-year initiative is a collaborative effort between Mount Sinai and City Health Works, a Harlem-based not-for-profit organization started in 2012 that trains community members to be health coaches. Coaches meet patients at their homes or within the community and work with clinicians on care plans. CHW currently works with about 400 patients, with coaches also serving as a bridge between healthcare professionals and the community by communicating with clinicians about any social factors they find that may be hindering a patient’s progress toward achieving their health goals.

City Health Works founder and Executive Director Manmeet Kaur said the collaboration with St. Luke’s came about as a result of CHW’s past success working with outpatient providers on improving their patients’ management of conditions like diabetes, hypertension and asthma. According to CHW, health coaches were responsible for helping to identify a medical issue unknown to a provider in half of patients they served.

She said the hospital will evaluate the program over the next six months to measure primary and secondary outcomes. Mount Sinai hopes to expand the service across the entire system based on the results. Kaur said plans were already underway to scale up CHW to offer its services to providers in areas of Brooklyn and the Bronx.

Kaur said CHW has to date been largely funded with philanthropic support as the organization developed its care model, but she said the organization is prepared to make the transition of scaling up to take on contracts for its service.

She saw CHW as an ideal service for those healthcare providers that have already transitioned a significant share of their patients covered in risk-based contracts.

“We’re now at the stage where we’re operationally preparing for that type of scale-up in other states in addition to growing in New York,” Kaur said.

Within 10 minutes of receiving a 911 call that a 61-year-old man had passed out, a paramedic and a doctor pulled up outside J.K. Lewis Senior Center in a red SUV.

The health care duo checked the patient’s heart rate, blood pressure and temperature.

Last year, the man would have been taken by ambulance to the ER to receive treatment for his dehydration.

Memphis Fire is one of several agencies across the country that is rethinking 911 services for non-emergency calls like this and at the same time addressing health care needs of patients they are called to assist.

The city has the largest 911 EMS/ambulance service in the state. Last year, the fire department had 130,000 EMS calls and of that number 25,000, or about 1 in 5 were categorized as non-emergency.

“That doesn’t mean they are not urgent to the people who are calling, it means that 22 percent were non-life threatening. So we recognized those kinds of calls were tying up our resources, so we wanted to make sure we have the right resource available at the right time,” said Memphis Fire Department Director Gina Sweat.

In April, the fire department launched the “Right Response” a pilot program that pairs a doctor and a paramedic for non-emergency calls.

“We recognized that with our EMS system the call volume continued to increase year after year and city budgets don’t always increase in line with that need, so we recognized that if this continued it would be a point to where we wouldn’t be able to provide efficient service,” Sweat said.

‘The Right Response’
Memphis paramedic/firefighter Rebecca Luckey drives the rapid response SUV on a recent Tuesday morning as Dr. John David Williamson with Resurrection Health navigates through the 911 calls on a laptop.

Since 8 a.m., the two have been on three house calls. Sending an ambulance to those calls instead would have cost the patient $850 to go to the ER for non-life threatening illnesses.

After treating the patients, the two provide them with information about a primary care doctor if they need one, and most do. They also secure them a ride to a doctor’s office.

Since the “Right Response” program launched five months ago, the doctors and paramedics have responded to more than 600 calls. The pilot program costs roughly the price of two firefighter/paramedic salaries -which is about $55,000.

The fire department has partnered with Resurrection Health who provides doctors to ride with the paramedics on the calls. The Plough Foundation provided grants that bought the two SUV’s that are used on house calls.

Other health care organizations have provided staffing or funding for the initiative including the Assisi Foundation, Saint Francis Hospital, Baptist Memorial Healthcare, Regional One Health, Christ Community Healthcare, Methodist Le Bonheur Healthcare and Innovate Memphis.

“Right Response” is a pilot project now, but fire officials hope to make it permanent.

‘Can I speak with the nurse?’
This month, another phase of the project will launch and will have a nurse working at the 911 dispatch center to talk with residents and assess their health care needs.

“We realize those residents are calling us because they don’t know where else to turn,” said Sweat. “If it is not an emergency, residents can speak directly with the nurse.”

The community paramedicine or telemedicine concept is gaining momentum across the country, said Matt Zavadsky, president-elect of the National EMT Association.

Zavadsky said their data shows that 210 EMS systems in the United States have programs operating as “mobile integrated health” and they coordinate house calls and telemedicine through 911 systems, fire departments and local health departments.

Zavadsky, who is the chief strategic integration officer for MedStar Mobile Healthcare in Fort Worth, Texas said their mobile integrated health project started in 2009. It includes a nurse in the 911 center and an 11-person team of paramedics and a nurse case manager who manage the high utilizer group or HUGS – patients who frequently call 911 for non-emergencies.

“We have seen, with the high utilizer program, there is about a 55 percent reduction in 911 and emergency department use with the patients who enrolled in the program,” Zavadsky said. “With our nurse in our communication center, about 33 percent of the calls go to the nurse. They don’t even get an ambulance response because people will say “can I speak with the nurse?”

He added that the programs are helping patients avoid costly and time-consuming trips to the emergency room and helping improve their health care needs.

“Nationally, these programs are taking off primarily because of the economic incentives today for hospitals. Third-party payer insurance companies are really focusing on value,” Zavadsky said. “I will be the first to tell you, I have been in EMS for 37 years and there is more value in navigating someone through the health care system than just simply schlepping every person that calls 911 to the emergency room.”

Though many emergency rooms are overcrowded and some patients may not have urgent needs, just a fraction of visits are truly “avoidable,” according to a new study.

Researchers examined data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011 that included more than 115,000 records representing 424 million emergency department visits, and found that only 3.3% were avoidable. The study team defined avoidable visits as those that did not require diagnostic tests, screenings, procedures or medications.

A number of these avoidable visits were for concerns that the ER is not equipped to treat, like dental or mental health issues, according to the study. Of the avoidable visits, 6.8% were for alcohol- or mood-related disorders, like depression or anxiety, while 3.9% were for dental conditions.

The findings, published in the International Journal for Quality in Health Care, challenge the commonly held belief that many people visit the ER needlessly, said Rebecca Parker, M.D., president of the American College of Emergency Physicians, in an announcement.

“Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise,” Parker said. “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that—myths.”

The ER has been a frequent target for initiatives seeking to reduce overuse and the costs associated with emergency care. However, the researchers said that their findings point more toward the value in programs to improve patient access to services like mental health and dental care.

The study found that 10.4% of visits from patients with alcohol-related disorders and 16.9% of visits from patients with mood disorders were avoidable, suggesting that policymakers could do more to increase access to the services that would keep those patients out of the ER.

“Our findings serve as a start to addressing gaps in the U.S. healthcare system, rather than penalizing patients for lack of access, and may be a better step to decreasing ‘avoidable’ ED visits,” the authors wrote.

Overcrowded emergency rooms are common in hospitals across the country. But several key strategies unite the facilities that are most effectively tackling this problem, according to a new study.

Researchers stratified hospitals into three groups based on data from the Centers for Medicare & Medicaid Services: highest-performing, high-performing and low-performing, according to the Annals of Emergency Medicine study.

They chose a representative sample of 12 hospitals, four from each group, and interviewed 60 leaders across those hospitals to determine what was working to reduce overcrowding.

Four strategies, which could be replicated in other hospitals, were identified:

• Executive buy-in: Leaders in the highest-performing hospitals had identified overcrowding as a key problem for them to solve, setting goals and providing the resources to accomplish them.
• Responses coordinated across the hospital: Hospitals in the low-performance group often operated in silos, while the highest-performing deployed strategies that required coordination between departments.
• Use of data: High-performing hospitals gathered and leveraged data to adjust ER operations in real time and to provide feedback to key staff members. Predictive analytics allowed ER staff to map needs and estimate patient flow.
• Accountability: The highest-performing hospitals addressed issues immediately and held staff members accountable.

Benjamin Sun, M.D., a professor of emergency medicine at Oregon Health & Science University and the study’s senior author, said in an announcement that overcrowded ERs can be dangerous for patients, so finding a solution to the issue is crucial.

“Emergency department crowding can be dangerous for patients,” he said. “We know, for example, that emergency department crowding can lead to delays in pain medications for patients with broken bones, as well as delays in antibiotics for patients with pneumonia. We know the risk of death is higher when the emergency department is more crowded than when it’s less crowded.”

Hospitals have deployed a number of programs aimed at reducing overcrowding in the emergency department. Baptist Health South Florida, for instance, introduced “tele-triage” to address patients with minor injuries or other common, but not urgent, maladies.

Others have hired “bed czars” to monitor flow in the ED or have launched fast-track programs to speed up treatment for patients with minor needs.

Nothing seemed to help the patient — and hospice staff didn’t know why.

They sent home more painkillers for weeks. But the elderly woman, who had severe dementia and incurable breast cancer, kept calling out in pain.

The answer came when the woman’s daughter, who was taking care of her at home, showed up in the emergency room with a life-threatening overdose of morphine and oxycodone. It turned out she was high on her mother’s medications, stolen from the hospice-issued stash.

Dr. Leslie Blackhall handled that case and two others at the University of Virginia’s palliative care clinic, and uncovered a wider problem: As more people die at home on hospice, some of the powerful, addictive drugs they are prescribed are ending up in the wrong hands.

Hospices have largely been exempt from the national crackdown on opioid prescriptions because dying people may need high doses of opioids. But as the nation’s opioid epidemic continues, some experts say hospices aren’t doing enough to identify families and staff who might be stealing pills. And now, amid urgent cries for action over rising overdose deaths, several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.

Blackhall first sounded the alarm about drug diversion in 2013, when she found that most Virginia hospices she surveyed didn’t have mandatory training and policies on the misuse and theft of drugs. Her study spurred the Virginia Association for Hospices and Palliative Care to create new guidelines, and prompted national discussion.

Most hospice patients receive care in the place they call home. These settings can be hard to monitor, but a Kaiser Health News review of government inspection records sheds light on what can go wrong. According to these reports:

In Mobile, Ala., a hospice nurse found a man at home in tears, holding his abdomen, complaining of pain at the top of a 10-point scale. The patient was dying of cancer, and his neighbors were stealing his opioid painkillers, day after day.

In Monroe, Mich., parents kept “losing” medications for a child dying at home of brain cancer, including a bottle of the painkiller methadone.

In Clinton, Mo., a woman at home on hospice began vomiting from anxiety from a tense family conflict: Her son had to physically fight off her daughter, who was stealing her medications. Her son implored the hospice to move his mom to a nursing home to escape the situation.

In other cases, paid caregivers or hospice workers, who work largely unsupervised in the home, steal patients’ pills. In June, a former hospice nurse in Albuquerque, N.M., pleaded guilty to diverting oxycodone pills first by recommending prescriptions for hospice patients who didn’t need them and then intercepting the packages with the intention of selling the drugs herself.

Hospice, available to patients who are expected to die within six months, is seeing a dramatic rise in enrollment as more patients choose to focus on comfort, instead of a cure, at the end of life.

The fast-growing industry serves more than 1.6 million people a year. Most of hospice care is covered by Medicare, which pays for hospices to send nurses, aides, social workers and chaplains, as well as hospital beds, oxygen machines and medications to the home.

There’s no national data on how frequently these medications go missing. But “problems related to abuse of, diversion of or addiction to prescription medications are very common in the hospice population, as they are in other populations,” said Dr. Joe Rotella, chief medical officer of the American Academy of Hospice and Palliative Medicine, a professional association for hospice workers.

“It’s an everyday problem that hospice teams address,” Rotella said. In many cases, opioid painkillers or other controlled substances are the best treatment for these patients, he said. Hospice patients, about half of whom sign up within two weeks of death, often face significant pain, shortness of breath, broken bones, or aching joints from lying in bed, he said. “These are the sickest of the sick.”

Earlier this year in Missouri, government investigators installed a hidden camera in a 95-year-old hospice patient’s kitchen to investigate suspected theft. A personal care aide was charged with stealing the patient’s hydrocodone pills, opiate painkillers, and replacing them with acetaminophen, the active ingredient in Tylenol. Hospice nurses in Louisiana and Massachusetts also have been charged in recent years with stealing medication from patients’ homes.

But many suspected thefts don’t get caught on hidden cameras, or even reported.

In Oxnard, Calif., in 2015, a person claiming to be a hospice employee entered the homes of five patients and tried to steal their morphine, succeeding twice. The state cited the hospice for failing to report the incidents.

In Norwich, Vt., in 2013, a family looked for morphine to ease a dying patient’s shortness of breath. But the bottle was missing from the hospice-issued comfort care kit. The family suspected that an aide, who no longer worked in the home, had stolen the drug, but they had no proof. State inspectors cited the hospice, Bayada Home Health Care, for failing to investigate.

David Totaro, spokesman for Bayada Home Health Care, told KHN that situations like that are “very rare” at the hospice, which takes precautions, such as limiting medication supply, to prevent misuse.

There is no publicly available national data on the volume of opioids hospices prescribe. But OnePoint Patient Care, a national hospice-focused pharmacy, estimates that 25 to 30 percent of the medications it delivers to hospice patients are controlled substances, according to Erik Jung, a vice president of pharmacy operations.

Jung said company drivers deliver medications in unmarked cars to prevent attempted robberies, which have happened on occasion.

Two recent studies suggest hospice doctors and social workers across the country are not prepared to screen patients and families for drug misuse, nor to address the theft of pain medication.

For family members struggling with addiction, bottles of pills lying around the house can be hard to resist. Sarah B., a 43-year-old construction worker in Vancouver, Wash., said when her father entered hospice care at his home in Oregon, she was addicted to opioids, stemming from a hydrocodone prescription for sciatica.

After he died, hundreds of pills were left on his bedside table. She took them all, enough Norco, oxycodone and morphine to last a month.

“I have some shame about it,” said Sarah, who declined to give her full last name because of the nature of her actions.

Sarah, who was one of her father’s primary caretakers, said the hospice “didn’t talk about addiction or ask if any one of us were addicts or any of that.”

“No one gave us instructions on how to dispose of all the medications that were left,” she added.

Medicare requires hospices to establish a safe way to administer drugs to each patient — by identifying a reliable caregiver, staff member or volunteer to manage the drugs or, if need be, relocating the patient. And it requires hospices to set policies, and talk to families, about how to safely manage and dispose of medications.

But there’s little oversight: Unlike nursing homes, hospices may go years without inspection, and even when they are cited for noncompliance, they rarely face any consequence except coming up with a plan to improve.

And in most states, hospices have little control over the pills after a patient dies. The U.S. Drug Enforcement Administration encourages hospice staff to help families destroy leftover medications, but forbids staff from destroying the meds themselves unless allowed by state law. Leftover pills belong to the family, which has no legal obligation to destroy them or give them up.

However, some states are taking action. In the past three years, Ohio, Delaware, New Jersey and South Carolina have passed laws giving hospice staff authority to destroy unused drugs after patients die. Similar bills moved forward in Illinois, Wisconsin and Georgia this year.

In Massachusetts, one of the states hit hardest by drug overdose deaths, VNA Care Hospice and Palliative Care advises families to empty leftover pills into kitty litter or coffee grounds before disposal — a common practice to prevent reuse, since flushing them down the toilet is now considered environmentally hazardous.

But families “don’t have to comply,” said VNA Care medical director Dr. Joel Bauman. “Our experience is maybe only half do. We don’t know what happens to these medications. And we have no right, really, to further inquire.”

Hospices across the country told KHN they take precautions, including counting pills when nurses visit the homes, limiting the volume of each drug delivery, giving families locked boxes for medication and giving patients random urine tests. They also said they prescribe medications that are harder to misuse, such as methadone.

Some, like VNA Care, have also started screening families of patients for history of drug addiction, and writing up agreements with families outlining the consequences if drugs go missing.

But “there’s so much moral distress” about punishing dying patients for family members’ actions, said Bauman. He said he tries to avoid doing that: “Why should we fire a patient for having inappropriate pill counts, when it may not be their fault in the first place?”

Though Blackhall helped spark a national discussion about hospice drug diversion, she said she’s also worried about restricting access to painkillers. Hospices must strike a balance, she said.

“It’s important to treat the horrible suffering that people have from cancer,” said Blackhall. But substance abuse is another form of suffering which is “horrible for anyone in the family or community that might end up getting those medications.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Health care is moving at the speed of light, and for many health system CEOs that requires a need for agility to tackle what’s now and what’s next. Deloitte recently surveyed 20 CEOs from large health systems across the country to uncover what’s top of mind and how they are moving forward in an uncertain – and sometimes challenging – market.

While none of the key themes emerging from our interviews around funding, value-based care, talent, and technology have really changed since we last spoke with health system CEOs in 2015, the urgency certainly has. Instead of talking about their 10-year plans like they did two years ago, these CEOs are now concerned with what’s happening now, and what might happen with Medicaid tomorrow. Many top concerns are compounded by uncertainty around the new administration, Congress, and the future direction of federal health care policy.

Top concerns among health system CEOs include:
• Preparing for potentially changing Medicaid reimbursement models and other policy issues
• Implementing population health and value-based care
• Maintaining or improving margins
• Recruiting and retaining top talent, including health care leaders
• Keeping up with evolving technology and cybersecurity risks
• Adapting to changing consumer demands and expectations

I’m not surprised health system CEOs are concerned about policy and federal funding. The debate around health care reform has dominated the news cycle since January. However, despite the uncertain outcome and impact of Congress’s health care reform efforts, there are, what I call, “no regrets” pursuits that health systems and hospitals can consider.

These include:
• Integrating business vertically
• Triaging patients to direct them to the appropriate level of care
• Reducing cost and inefficiencies across the system

Vertical integration
As we know, health care is changing. For years, there has been little incentive for hospitals to direct patients to – or coordinate with – step-down or other less expensive settings of care. But now that is changing. Government payment models such as those promoted through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), along with commercial value-based reimbursement agreements, are helping push many hospitals to reconsider their relationships with other health care stakeholders.

Depending on a hospital’s patient population, it might make sense to vertically integrate with other health care partners. This could include payers, post-acute care facilities, and physician practices. If revenues aren’t going to increase, hospitals and health systems may need to think about new revenue streams. An integrated care delivery system can help coordinate care across the continuum and track patients more efficiently.

Triaging patients
Another strategy health system leaders could consider would be to implement stronger triaging systems that help direct patients to the most appropriate care setting. If a hospital or health system is vertically integrated, and owns or partners with urgent care clinics and/or physician practices, it can refer patients to those settings rather than providing care in the emergency department (ED), which can cost thousands of dollars per hour to operate. If an increasing number of uninsured patients come to the ED – and hospitals anticipate more uncompensated care – there is likely a financial incentive to actively direct some of these patients to a lower-cost and/or more appropriate care settings.

Reducing inefficiencies
Though many health systems have looked for efficiencies around the margins of providing care, they now likely need to find greater clinical efficiency. They might need to rethink how care is delivered and at what cost. Generally, reimbursement is not increasing in the government or commercial sectors. As many hospitals continue to take on more risk, it will likely be important to deliver care as efficiently and effectively as possible. Though many health system CEOs have found new revenue streams through the acquisition of physician practices and other hospitals, they might not yet understand how to operate as a system. Hospitals within a health system sometimes continue to operate independently of one another rather than tapping into their synergies.

Though the health care debate is ongoing, and the future of the Medicaid program is unclear, there are strategies that health system CEOs can pursue today. Regardless of what happens with Medicaid, government and commercial payers are likely not interested in paying hospitals more than they already do. Looking for ways to vertically integrate, triage patients, and reduce inefficiencies can help prepare hospitals for a value-based reimbursement system. Health system CEOs should consider how to deliver care to patients in the most cost-effective way possible. The organization leaders that figure this out first will be the ones shaping the future of health care, and those health system CEOs will sleep much more soundly.

The benefits coming from the CMS’ Hospital Readmissions Reduction Program have slowed enough that some industry experts and hospital leaders say it may be time to retire the program.

The program was mandated by the Affordable Care Act as part of a larger effort to curb health costs—readmissions make up about $41 billion in healthcare spending—and to motivate providers to improve outcomes.

By and large, the program seemed to work. The CMS’ spending on readmissions fell $9 billion by 2014 and readmission rates for Medicare beneficiaries suffering congestive heart failure averaged 22% from 2011 to 2014, down from 24.5% from 2005 to 2008, according to a Kaiser Family Foundation analysis of CMS data. But there has been a standstill on progress. From 2013 to mid-2016, readmissions have only dropped by 0.1% on average. Moreover, since the CMS began to dock U.S. hospitals for their readmission rates, a majority have consistently fallen victim to the penalty.

The minuscule movement now plaguing the program might mean it’s time for the CMS to move on, said Dr. Thomas Balcezak, chief medical officer of Yale New Haven (Conn.) Hospital, a safety-net academic medical center. The hospital received a 1.91% penalty this fiscal year and will be hit with a 1.7% penalty next year.

In 2013, the first year the reduction program issued penalties, 2,217 hospitals were hit with Medicare cuts. In its most recent round, the CMS expects 2,573 hospitals will get a penalty in the upcoming fiscal year. Each year, about 75% of the roughly 3,200 affected hospitals see up to 3% of their Medicare payments reduced because patients return 30 days after discharge. The CMS excludes psychiatric, critical-access and children’s hospitals as well as hospitals in Maryland because of its unique all-payer rate-setting system.

The CMS did not respond to requests for comment.

For those known as the “familiar faces” most likely to dial 911, this island city across the bay from San Francisco is trying a new approach – getting in touch with them before they call.

“It changes the role we’ve traditionally had with folks,” said Patrick Corder, part of the local fire department’s Community Paramedic Program who used to spend his shifts racing to fires and accidents. “911 is purely reactive. This position is proactive.”

The program is part of the state’s two-year pilot study to look at whether local agencies can save money and improve lives by using firefighters and paramedics to check on the highest users of their services. A study of the program’s first year, 2016, showed a 37 percent decrease in visits by frequent users to the local hospital’s emergency department.

The program, administered by the state Emergency Medical Services Authority, involves 13 departments around the state that are using paramedics to check on people recently released from hospitals, admitted to sober centers, and are most likely to use emergency services. Only two agencies, in Alameda and San Diego, are enrolling the most frequent users of 911. While the program’s initial funding ends this year, there is pending state legislation that may extend it.

These days Corder and another paramedic in the program can be found, as he describes it, “trying to put out figurative fires” – checking on about a half dozen regulars who might be homeless, recently released from the hospital or in precarious health.

One recent day began with a few calls to patients getting ready to leave the hospital and one to another who’d moved to Auburn but was still unsettled. A meeting was set up with a woman who had “graduated” from the program after 30 days but wanted to talk to Corder about her concerns over moving to an assisted living home.

“I promised her I’d follow up,” said Corder, sitting in his office in one of the buildings dotting a former military base on the island. “Her family wants her to move, and she has a lot of questions. She’s anxious.”

If his visit keeps the woman “happy and healthy,” and prevents her from needing to rely on 911 – as she’d frequently done in the past – he was glad to visit, he said. He will check her vital signs and whether she’s taking medications correctly, as he does on all home visits, but mostly what he does is “less medical and more social welfare,” he says.

Later in the day he will head to his fire-red car, which holds emergency medical supplies and equipment, make a hospital visit and then look for another man enrolled in the program who is homeless.

“I know where he’s likely to be,” said Corder. “Any one of three places.”

So far Corder has helped the man find a primary care doctor and get his prescriptions refilled. He’s also written a letter of support, requested by the public defender seeking to get a criminal charge reduced. With a cleaner record, Corder said, the man would have a better chance of getting housed.

“The thing that surprised me was the eagerness and willingness of paramedics to work on social needs and to be very patient and caring with folks who had mental illness and substance abuse,” said Janet Coffman, an associate professor at UC San Francisco School of Medicine and coauthor of a report on the pilot program.

Alameda, with a population of just under 80,000, enrolled 40 people in the first year and saved $8,114 a month in emergency department transports and visits, according to the report. Similar programs outside California have been successful in reducing hospital admissions, Coffman said, and there’s evidence a small program like the one in Alameda can work in larger cities.

She credited some of the programs’ success to “robust training” where paramedics learn how to recognize and handle needs of the high-risk population. Corder said it had given him a closer look at the complicated, inter-related health system. He now talks regularly with social workers at the hospital to enroll people who have little or no help when they’re released.

The program offers services to hospitalized people with chronic heart or lung disease, diabetes, pneumonia or sepsis. Once released, Corder and his partner might refer them to prevention services, meal programs or senior centers where they won’t be isolated. Not all interventions work. Some people in the program disappear or reject help.

“It’s not what I initially signed up for,” said Corder, who’d been in the department seven years when he volunteered for the program. But he found the assignment a good fit, both because he studied psychology in school and is from Alameda.

He and his partner have helped people get identification cards at the DMV and helped clean an unusually cluttered apartment. And they’ve attended funerals.

“It’s been a blessing in the way that I can really communicate with people and follow them at what is often the end of their lives,” Corder said. “A lot of people had their whole lives here. Sometimes I’m just there to be a witness.”

In an elaborate scheme for scammers to get cash, some people are being led to believe their loved ones are in danger. Maria Mejia said she was working at a North Texas hospital when her phone began ringing repeatedly one afternoon.

When she answered, the person on the other end of the line claimed to a paramedic and had a man hurt, who listed her as an emergency contact. “I said, ‘What’s his name?’ They said, ‘Ma’am, he’s unidentified, unconscious,'” Mejia said.

The caller asked Mejia for the name of her father, husband or brother and what type of car they drove. When she told him, she said he screamed to someone to check to see if the crashed car was a black Suburban and then came back to the phone.

“He says, ‘That’s your dad in the accident.’ I started crying, I was shaking, I was scared,” Mejia said. Her co-workers saw she was shaken and rushed to her side as the call went on.

“He said, ‘Your dad was exiting Exxon, and he hit a 17-year old on a motorcycle, and the 17-year old was my son, and now your dad is going to pay for the damages,'” Mejia said.

The story had changed. Now, she’s got an angry family member, wanting money.

Before she could wrap her head around that, it changed again.

“He said he was kidnapped, they took him to apartments, and that he had my dad’s phone, and if he received call or texts from you or anybody, ‘We’re going to put a bullet in your dad’s head,'” Mejia said. The caller wanted $3,000 in ransom. She didn’t know any longer if this was an angry father, kidnapper or a paramedic.

“My coworker told me ask him for a picture of your dad. So, I said I want a picture of my dad. He said, ‘Lady are you listening? We have your dad kidnapped and we’re going to put a bullet in his head.’ He said, ‘You can save the money for the funeral.’ He said, ‘Maria are you there?’ I started to respond but he hung up,” Mejia said.

Mejia said she was too panicked to doubt the story. She didn’t want to call him back either.

“I was scared, because he said if he gets a call they’re going to blow his brains out,” Mejia said. Instead, she called 911, and reached a dispatcher who called her dad, conferenced him in, and her dad said he was home, safe and doing chores.

The 911 dispatcher told her they’ve gotten calls like this before, but the Dallas Police Department said it wasn’t familiar with them. Other departments were saying the scheme almost always starts with a loved one who is hurt and a paramedic needing cash.

Macara Trusty is a paramedic with MedStar. She says anytime you get a call from someone claiming to be an emergency responder with a critical patient, that’s a red flag. “If the patient is so critical that they can’t talk on the phone, we don’t have time to make those phone calls,” Trusty said.

Police are investigating these calls but want you to know just because the number pops up as local doesn’t mean the caller is in town or even in the country.

If you do get a call like this, police ask you to file a report.

From what BlueCross BlueShield of New Mexico has found, establishing a partnership with community paramedics is not only good medicine, it’s good for business.

The insurer’s Community Paramedicine program, which started out as a pilot project in the fall of 2015, is targeted at Medicaid members who have either been identified as emergency room super-users or are at high risk for readmission within 30 days of being discharged from the hospital.

BCBSNM chose those two populations because “we thought we could track those well and see if this is working,” Duane Ross, M.D., the insurer’s medical director, told FierceHealthcare.

Now, the insurer has produced promising preliminary results.

Since the program’s full launch in 2016, BCBSNM estimates that it saved $1.7 million—after taking into account the cost of the program itself. Among the 1,100 participating members, there was a 62% reduction in ER utilization and a 63% reduction in ambulance usage.

In addition, the 30-day readmission rate among BCBSNM’s members has dropped from 15% to 11.2% since it began the paramedicine program. While the insurer has undertaken multiple initiatives to lower that percentage, “we’re confident that this program was a big part of that reduction,” Ross said.

Just as important, Ross added, is the fact that “the paramedics indicate they’re actually very happy to be able to see people proactively rather than in a reactive fashion.”

The anatomy of a house call

Most BCBSNM members involved in the Community Paramedicine program receive only one house call, Ross said—though there occasionally might be a follow-up visit.

First, though, they always call the member to ensure they’re OK with the visit taking place. As Ross puts it: “You don’t want to have a person in uniform knocking on your door unexpectedly.”

Paramedics who conduct house calls are tasked with ensuring that patients know all the information related to their diagnosis; who their primary care physician is and how to use primary care services; and how to reach a care coordinator with BCBSNM.

The primary-care discussion is particularly important for ER super-users who did not previously have insurance before signing up for Medicaid, Ross noted, because they tend to have a long-established habit of getting all their care through the emergency room.

“Sometimes it takes a visit to get them to make that switch,” he said. “Surprisingly, it actually sticks fairly well once they’re shown how to do that.”

Paramedics also conduct a home assessment to check, for instance, whether the residence has any hygiene issues, whether there are fall hazards and whether there’s food in the refrigerator. While paramedics can check patients’ vital signs, Ross noted, they don’t typically administer any other type of care.

For patients at risk of readmission, paramedics take the extra step of making sure they understand—and can follow—the hospital’s post-discharge care plan. That can involve ensuring they have a way to pick up any needed medications and know how to take them, and ensuring that they’re aware of and can find transportation to follow-up doctor visits.

Crucially, Ross, said, “we’re trying to get to them within 48 hours of the discharge, because if they lack transportation to pick up prescriptions, supplies or anything like that, the clock is ticking before they find themselves back in the hospital.”

Paramedics as partners

BCBSNM’s program is hardly the only instance of paramedics rethinking their traditional role as emergency responders.

For example, the North Memorial Health system in Minneapolis started a program in 2012 that used community paramedics to conduct home visits with patients who visited the ER nine or more times in a year. Similarly, the Valley Hospital in Ridgewood, New Jersey, launched a program 2014 to provide proactive, post-discharge home check-ups to certain patients with cardiopulmonary disease who are at high risk for readmission.

“This is actually a big movement,” Ross said. In fact, in Albuquerque, “the paramedics in the community had been looking at something like this for a while, but had not been able to get some of the logistics worked out.”

Therefore, BCBSNM figured out a “claims-based approach” to pay for home visits, which helped get the program off the ground. The result is the insurer has control over how many home visits are going to occur and who will receive them.

Besides working out a payment model, another secret to the Community Paramedicine program’s success is that the person running it is a paramedic himself, Ross noted. That helps establish trust and communication with the paramedic companies involved.

While BCBSNM is happy with the current scope of the program, in the future it’s interested in looking at the possibility of having paramedics conduct multiple visits with patients who have chronic conditions to help stabilize them, Ross said.

The insurer is also hoping to expand the program to cover more geographic areas than those in which it currently operates: Albuquerque, Belen, Rio Rancho, Las Cruces and Alamogordo. Because the paramedicine project has produced positive results and been well-received by paramedics, Ross said, “it’s easier to go out to more far-flung ambulance companies and even fire departments.”