News & Updates

FORT WORTH, Texas — Her mother’s breathing had become labored in the wee hours of the night, during what would prove to be the Fort Worth woman’s final days living with lung cancer. Distraught, the daughter called 911.

“Her mother was having some pretty severe shortness of breath,” said Tim Gattis, the third paramedic to arrive on scene late last year. “She was certainly working very hard to obtain a breath, and was just not being successful.”

Gattis pulled up in a sports utility vehicle shortly after the ambulance had arrived, and the first two responders were already loading the 64-year-old woman into the back. The daughter was insisting that her mother go straight to the hospital, Gattis said.

But the role of Gattis and other Fort Worth paramedics trained for this type of hospice support — part of a local partnership with VITAS Healthcare, the country’s largest hospice organization — is to spend a longer stretch of time on the scene to determine if the symptoms that triggered the 911 call can be addressed without a trip to the emergency room. MedStar Mobile Healthcare, a governmental agency created to provide ambulance services for Fort Worth and 14 nearby cities, is one of several ambulance providers nationwide that have teamed up with local hospice agencies. The paramedic backup, enthusiasts argue, not only helps more hospice patients remain at home, but also reduces the potential for costlier and likely unnecessary care.

On average, 18 percent of hospice patients go to the emergency room at least once before their death, according to an analysis of Medicare data published last year in the journal Medicare data published last year in the journal Medical Care. Melissa Aldridge, the study’s lead researcher and an associate professor at New York City’s Icahn School of Medicine at Mount Sinai, describes paramedic-hospice partnerships such as Fort Worth’s as “forward-thinking” in promoting better patient care.

Hospices also can financially benefit, she said, since they’re paid a flat rate — typically just under $200 a day — regardless of where their patients are treated. So, any hospital treatment related to the patient’s condition, such as pain stemming from advanced cancer, would come out of that payment, she said. “For [the agencies], it could definitely be worth it, particularly for the one or two outlier families who seem to be using the emergency department fairly heavily during a hospice stay,” Aldridge said.

An Expanding Role
These emerging programs rely upon a new type of emergency responder. Dubbed community paramedics, they can offer a range of in-home care and support for home health patients, frequent 911 callers and others to reduce unnecessary ambulance trips. MedStar’s community paramedicine program had already been launched, when VITAS got in touch.

The Affordable Care Act had been passed, and with it the inclusion of financial penalties for hospitals if their patients return too quickly to the hospital. John Mezo, senior general manager for the Fort Worth region of VITAS, said that since many VITAS patients come from hospital referrals, it’s important that the hospice not become “a big problem for our referral sources,” he said.

So in 2012, Fort Worth’s VITAS program began contracting with MedStar, targeting patients who have been flagged during the hospice admissions process as moderately to highly likely to call 911 or end up in the hospital. (VITAS pays a flat monthly fee to MedStar for each patient enrolled.)

Once signed up, hospice patients calling 911 can be identified through various routes, including their address, name or phone number. Then a community paramedic like Gattis, who is available for home health and other types of calls, including hospice, is dispatched along with the traditional ambulance response, said Matt Zavadsky, MedStar’s chief strategic integration officer. The ambulance provider now contracts with two hospice agencies and is in talks to add others, he said.

In Ventura, Calif., a similar hospice initiative is being piloted through a state agency — part of a larger multicity effort there to study the use of community paramedics. That pilot, which has worked with some 20 hospice agencies since 2015, sends out a community paramedic to any 911 call involving a hospice patient. Also, a large Long Island, N.Y.-based health care system added similar paramedic backup last year for a portion of its hospice patients living in Queens under a grant-funded project.

If any of those nearly 180 patients or their family members calls the 24/7 hospice number with an urgent situation, a community paramedic can be immediately sent, said Jonathan Washko, assistant vice president of emergency medical services for the system, Northwell Health.

It’s “extremely rare” that patients call 911 directly, Washko said, “because we get them help, just as if they would have called 911.”

Navigating Final Days
The uncomfortable truth is that a patient on hospice can develop unsettling and sometimes scary symptoms during their final weeks or days. Secretions can accumulate in the throat, which might sound like choking, even though the patient is not, Mezo said. The patient might suffer a breathing crisis or a seizure.

VITAS stresses that a hospice nurse is available around-the-clock, by phone or to stop by. But family members can understandably be loath to wait for a nurse who might have to drive from an hour away, Mezo said.

“When it’s your loved one there and you’re in charge of them, it’s very frightening,” he said. “If you’ve ever had to call 911, even five minutes waiting on an ambulance seems like an eternity, right?”

For paramedics involved, the work has proven to be challenging and gratifying, requiring a mix of psychology and social work skills along with medicine. “You can’t Google what to do in these situations,” said Ambrose Stevens, a Ventura community paramedic, who has responded to about 40 hospice calls.

By the end of 2016, Ventura paramedics had responded to 258 hospice calls, but paramedics needed to access hospice-provided medications for pain, nausea and other symptoms in fewer than 2 percent of those calls, said Mike Taigman, project manager of Ventura County’s Hospice Community Paramedicine Pilot Project. “Most of what we do is really helping coordinate, talk people down from being upset, helping remind them of what hospice is all about,” he said.

Offering The Option
Patients or their family members can still insist on going to the emergency room, and sometimes they do. Of the 287 patients enrolled in Fort Worth’s program for the first five years — all of whom had been prescreened as highly likely to go to the hospital — just 20 percent, or about 58 patients, were transported, according to MedStar data. In Ventura, ambulance transports for hospice patients calling 911 also have declined — from 80 percent shortly before the program’s start to 37 percent from August 2015 through December 2016, according to data provided by Taigman.

That difficult night in Fort Worth, Gattis put the VITAS nurse on speaker as they talked to the daughter about ways to keep her mother more comfortable at home. The daughter agreed to hold off on ambulance transport and see if anti-anxiety medication and morphine would ease her mother’s breathing struggles.

Within a half-hour, Gattis said, it was apparent that the medicine was helping. “She was feeling better to the point that she could eat a little bit of a sandwich.”

Gattis stayed for more than an hour until the hospice nurse arrived. The woman died several days later in her own bed.

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation. Coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Article can be accessed here.

The bill was expected Feb. 27 after a congressional recess, but was leaked to Politico and published Friday.

Most of the reconciliation bill is simply a more detailed version of the policy brief revealed last week — it would repeal Medicaid expansion, a host of taxes and dismantle current cost-sharing subsidies under the ACA — and replace those items with a number of proposals that have been popular with Republicans.

Here are the five most important details to know about the proposal, as reported by Politico.

1. The main revenue generator behind the bill is a cap on tax exclusion for employer-sponsored health insurance. The bill repeals a number of taxes and tax increases installed under the ACA including the medical device tax and health insurance tax, among others. In place of these taxes, the bill caps the amount employers can contribute tax-free to employees’ health plans. Benefits that exceed the 90th percentile of current premiums would be taxed, according to Politico. If that sounds familiar, that’s because the cap is similar to the ACA’s Cadillac tax on luxury employer-sponsored health plans, which was a 40 percent excise tax paid for by insurers. The unpopular tax was delayed due to opposition from companies and labor unions that would have had the costs passed down to them.

“Capping the exclusion is the same thing [as the Cadillac tax], but it’s a much more direct hit on companies and consumers,” Russell Sullivan, a partner at McGuireWoods and one of the principal drafters of the Cadillac tax, told Becker’s Hospital Review. Both the cap on employer exclusion and the Cadillac tax would put downward pressure on prices by discouraging overuse of healthcare services, which is common with generous health plans. Also similar to the Cadillac tax, the proposal will likely face opposition from businesses and labor unions, according to Mr. Sullivan. “This expands the battlefield,” he said.

2. The bill would roll back Medicaid expansion. Of course, states would have the option to continue with the expansion, but they would no longer receive enhanced federal funding to do so, which could make the option impossible financially. The bill lays out a proposal to instead cap federal Medicaid funding based on how many people qualify by state. However, to help offset the repeal of Medicaid expansion, the bill would restore cuts made to Medicare disproportionate share hospital payments under the ACA. The healthcare reform law reduced DSH payments presuming coverage would increase and the need for uncompensated care would decrease, particularly with Medicaid expansion.

3. The bill would also repeal the individual mandate and the premium subsidies. Instead of tying subsidies to income, they would be linked to age. Tax credits would start at $2,000 for people under age 30. They increase in steps of $500 per decade of life, reaching $4,000 for people over age 60. In the absence of the mandates, the bill would encourage people to maintain coverage by allowing payers to penalize beneficiaries for any lapses in coverage by increasing future premiums by 30 percent. It would also encourage more young, healthy people to buy health plans by increasing the age rating band tied to insurance plans from 3:1 to 5:1, according to Politico. This means insurers can charge older beneficiaries up to five times as much as younger beneficiaries for the same plan. Currently this ratio is limited at 3:1 under the ACA.

4. The bill also offers more detail on plans to help subsidize the cost of covering more expensive enrollees, such as those with pre-existing conditions. It would allot $100 billion in state innovation grants, which can be used in a number of ways at a state’s discretion to help offset the costs of high-cost patients. One option is the money could be used to reinstate high-risk pools for people with pre-existing conditions.
5. This bill is not finalized. The leaked version is still unnamed and unnumbered and considered a discussion draft. A number of issues are still disputed among Republicans. Representatives who held town halls about the ACA are finding their views are not as simple as for or against, The New York Times reported earlier this week. Leadership may also oppose certain elements. For example, Politico reported HHS Secretary Tom Price, MD, would want the subsidies to be lowered from the current proposal. Congress plans to take up discussion again next week when they return from recess.

Article can be accessed here.

In 2007, USA Today called Houston a city in crisis when it came to healthcare. Houston had among the worst wait times in the country for emergency care, and 40 to 50 percent of visitors to emergency departments really just needed primary care, which the area also had a severe shortage of. Ambulance diversions were common.

More recent research found that similarly high numbers of nonemergency calls to 9-1-1 were for primary care-related issues.

The Texas city, the fourth-largest municipality in the U.S., also had a perception problem with emergency medical services delivered through the Fire Department.

“Our fire trucks are capable of giving the same care as an ambulance,” Dr. Michael Gonzalez, deputy medical director for the Houston Fire Department, said at HIMSS17 in Orlando, Florida. But, he noted, people feel like there has been a mistake if a fire truck shows up when they call an ambulance, and sometimes demand an actual ambulance. That further ties up scarce resources.

“We are not built to handle primary care issues,” Gonzalez said. The Fire Department, as well as area EDs, can certainly deal with primary care on an episodic basis, but emergency physicians simply are not in a position to follow up with patients to address chronic health issues.

Since late 2015, telemedicine for ambulance-based triage has greatly alleviated several of the problems, HIMSS attendees heard Tuesday.

A program called ETHAN — for Emergency Tele-Health and Navigation — outfits emergency medical technicians with 4G-enabled tablets that connect to 9-1-1 services, the University of Texas Health Science Center, a nurse help line, a network of primary care clinics (for the purpose of getting people into medical homes) and even to a taxi service for transportation.

“We’re prepaying taxi vouchers on the premise that a Yellow Cab is a lot less expensive than an ambulance,” James Langabeer, professor of clinical informatics at the University of Texas, said during a joint presentation with Gonzalez.

The ETHAN system has allowed Houston EMS to offer mobile integrated healthcare, as defined by the National Association of Emergency Medical Technicians.

EMS telemedicine has been around in at least a rudimentary fashion since the 1970s, but Langabeer noted that it has not been widespread or comprehensive. “We’re using ours in a much broader way as an intervention for primary care-related incidents,” he said.

Firefighters and EMTs access ETHAN on tablets they had already been carrying. On the other end of the line is the nurse call center as well as a team of board-certified physicians in the Houston area.

The Fire Department has a partnership with the local health information exchange to pull in patient records from area hospitals so EMTs and the clinicians on the other end have at least some history on many patients they serve. These elements of ETHAN, Gonzalez said, have helped avoid repeat callers to 9-1-1 by getting people — many of whom had not seen a primary care physician in years — into medical homes so they can receive ongoing care to prevent future emergencies.

Fire Department crews have full leeway to decide whether to transport each patient they visit to a hospital ED or to lean on ETHAN for an alternative disposition, Gonzalez said.

Preliminary results of the program, as detailed in a paper published in December in the Journal of Telemedicine and Telecare, have been encouraging. With ETHAN, ambulances and fire trucks are back in service and ready to take on a new case a median of 39 minutes after being dispatched. Prior to the introduction of the telehealth program, it took a median of 83 minutes to get a vehicle back in service.

At the baseline, 74 percent of people for whom EMS was dispatched ended up being transported to an ED. That declined to 67 percent in the first year after ETHAN went live.

Patient satisfaction with Houston EMS actually ticked up slightly with ETHAN, to 88 percent from a baseline of 87 percent. And the city saved money at an annual rate of $928,000, based on the average savings of $2,468 per ED visit avoided.

Original article can be accessed here.

No one can predict the future of health care under a new administration or predict precisely when and how the Affordable Care Act’s (ACA) successor will become the new law of the land. We don’t know how stakeholders—including consumers—will be affected, or how far the regulatory changes will reach. In times like this, it’s tempting to sit back and wait until the direction is clear.

But that could be a mistake. The industry should not become paralyzed in the face of uncertainty. Now is the time to focus on the things that are and will continue to be critically important. It’s the time to focus on what I like to call the four “Cs” of health care: cost, customers, clinical quality, and consolidation. Regardless of what comes down from Washington, these fundamental elements will continue to be central and perhaps even more important to health care effectiveness and efficiency at the local, regional, and national levels.

Cost. The cost of care remains a pressing concern for providers. Questions persist about reimbursements, payment structures, and investment demands. Costs can’t just be tweaked around the edges; health care organizations need creative, meaningful solutions. Fortunately, there’s no need to start from scratch; leading providers are looking to other industries for proven ideas.

Effective cost containment tools and processes are available now. Think enabling the supply chain with digital, digitizing the finance function, and employing robotic process automation where it makes sense. Solutions such as these can help rein in an organization’s fixed-costs and support scalability. Providers need to be more aggressive about deploying them in the health care space.

Customers. It’s likely a growing share of medical care and coverage costs will be borne by the individual, a trend that started under the ACA. A recent study by the Health Care Cost Institute (HCCI) showed that individuals’ 2015 annual out-of-pocket costs increased to an average of $813, a 3-percent increase. The HCCI also found that 53 percent of customer health spending can now be comparison shopped.

As people grow more price sensitive and knowledgeable, they are likely to seek out more affordable medical options and those options which meet a broader set of needs including service expectations, access, and convenience. Meeting these demands will require providers to be more nimble and attentive to customers’ growing demands and changing needs to stay competitive.

Health care providers can learn a lot by studying customer-centric industry sectors, such as retail, financial services, and travel/hospitality. These types of businesses remain relevant to consumers by gathering insights on customer behaviors and perceptions and using them forge productive relationships. These industries have engaged with customers in ways health care sectors historically have not; their lessons can be instructive.

Clinical quality. The opportunity to improve outcomes, reduce variations in care, and establish better reimbursement models is central to the push for quality-based standards and practices. Providers should scrutinize their clinical quality and care models and introduce ways to reduce duplicative procedures, hospital readmissions, and mortality and morbidity rates. Organizations should look to drive continuous performance improvement in this area by building the foundational infrastructure necessary to drive quality performance across the enterprise holistically versus too intense of a focus on specific metrics.
Consolidation. Consolidation, while more speculative, could be one answer to addressing cost, customers, and clinical quality issues. Partnerships are forming in ways we couldn’t have fully imagined a decade ago, whether provider/provider, providers developing formal agreements with health plans, retailers, or more unique collaborations with outside players. Stakeholders in the provider space should actively pursue arrangements, perhaps even unorthodox ones that advance their interests.

Challenging, complicated work lies ahead. Winning health care organizations will not wait; they will continue driving toward higher-quality, lower-cost patient care while the Trump administration and Congress discuss a replacement for the ACA.
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About the Author
David is a principal in Deloitte Consulting LLP’s Life Sciences and Health Care practice. He leads Deloitte’s Customer Transformation initiatives for the health care provider sector, and his work has focused on enhancing core operations in the revenue cycle, driving performance improvement through operating model transformation and growing the business through mergers & acquisitions all with an eye towards creating a more patient-centric, consumer-oriented delivery system.

Original article accessed here.

More and more, physicians and health systems are treating patients less and less. But it’s not about “rationing” care or cutting expenses. It’s about rethinking old, outmoded practices to achieve more-effective, evidence-based “right care.”
Take, for example, getting people reinvigorated, out of bed and home faster after major surgery.

At Kaiser Permanente’s health plan in Northern California, members who’re slated for total joint replacement are now required to attend a two-hour pre-op class where they’re thoroughly briefed on what to expect — and what’s expected from them — before, during and after the procedure. They even get to pass around a sample of the hardware they’ll soon be wearing.

Three weeks later they get a telephone call from a nurse practitioner to review the instructions and schedule a blood test and an electrocardiogram. Chest X-rays are no longer routine. Ten days before the procedure they meet with the surgeon for a final OK. Joint replacement is elective, they’re reminded — and they have a shared responsibility to heal as quickly as possible.

At the class, they’re given a bag of goodies including brochures, checklists and pre-op instructions (e.g., discontinue nonsteroidal anti-inflammatory drugs and vitamins 10 days beforehand, no solid food within eight hours of the surgery, clear liquids OK until two hours before the procedure, and brush teeth for five full minutes on the morning of the surgery). There’s also a recommendation to wash with an acne cleansing bar the week before surgery (to eliminate a bacterium resistant to the usual antibiotics), a packet of antiseptic skin wipes to supplement the pre-op shower at home, two 4-ounce carbohydrate “sports fuel” juice packs to be drunk on the way to the hospital, and a spirometer to exercise the lungs after surgery to prevent pneumonia.

For most patients, anesthesia will be epidural not general. There’ll be no urinary catheter. And they’ll be coaxed to get up and head down a hallway (with a walker) as soon as feeling returns to their legs.

Best of all, they can usually expect to go home that same day.

Enhanced surgical recovery
This remarkably pared-down and systematized hip replacement protocol at Kaiser is the fruit of a major re-examination, undertaken in December 2013, of all surgical practices in its Northern California region.

“We drilled down to the evidence base and found that while we were doing what we thought the evidence supported, it really wasn’t always there,” says Stephen Parodi, M.D., associate executive director of Permanente Medical Group.
For example, he notes: “Surgery is a stressful physiological event. If you think about it, it’s kind of like running a marathon.” Nevertheless, surgery patients were always forbidden solid food and most fluids after midnight … “something,” Parodi observes, “no one would be told before running a marathon.”

In fact, the restriction was an administrative artifact, the researchers concluded. There’s no evidence-based risk to patients to allow them to drink Gatorade two hours before an operation; it’s not only safe, it prevents dehydration.
Based on the literature review, Parodi continues, teams of doctors, nurses, nutritionists and physical therapists working in two surgical units set about collaboratively designing protocols that would improve patient outcomes in their specialties as measured by “control of pain, adequate nutrition, time to being more mobile, faster recovery and time in hospital.” What was dubbed the Enhanced Recovery After Surgery program started with two complex procedures, colorectal surgery and hip fracture repair.

Over the next six months, says Parodi, the surgical teams hashed out: “What’s practical? How are [implementing these changes suggested by the literature] going to really work?’ They actually got very excited about it.”

Patients too played a major role as the redesign process unfolded, Parodi adds. “We asked, ‘Was the experience better or not? How can we make it better?’ We put together a calendar that would tell them what to expect and empower them to participate in their own care.”

By June 2014, new workflows had been plotted, piloted and tested. The teams had also specified exactly how Kaiser’s electronic health record system should incorporate updated prompts and best-practice alerts. Simple one-click ordering and order-change capabilities were built in. (For example, says Parodi, a doctor who prescribes an acid-suppressing antihistamine for an inpatient will see a warning that it has recently been found to promote Clostridium difficile infection; one corrective click spares the patient a potential hospital-acquired bout of diarrhea.)

“We try to make it easy for people to do the right thing,” Parodi says.

The ERAS model for colon and hip fracture surgery was introduced throughout Kaiser’s Northern California region in August 2015. Proof of success was documented by December of that year. From an average inpatient stay of eight days after a colon procedure, patients were (and are) being discharged in 5½ to six days, Parodi reports. Postsurgical stays after hip fracture repair have been reduced by a day or more. The rate of postsurgical complications has been pared as much as 17 percent.

With improved attention to nutrition before and after surgery (patients are immediately given gum to chew or hard candy to suck to aid in digestion of a soft meal soon after they leave the operating room), a sharp cutback in the amount of opiates used for pain control (relying on effective nonopiate drugs) and emphasis on early mobility, reports Parodi, patients experience “less nausea, so they’re able to eat sooner than they could in the past; they’re no longer delirious or sleepy after surgery, so they’re able to get up and walk sooner; and as a result, they recover faster and are able to go home.”

“It’s just night and day compared with what it used to be,” observes surgeon Efren Rosas, M.D.

In 2016, the ERAS model was expanded to include hip replacement and cesarean sections, and rolled out to all 21 Northern California Kaiser hospitals. This year will see its adaptation and adoption for every surgical procedure in the nine-state system’s Southern California, Hawaii and Pacific Northwest facilities.

Right care
Even as health care reform has led to reimbursement of doctors and hospitals based on the value rather than the volume of their services, evidence has mounted that “too much medicine happens too often,” to quote an editorial in JAMA Internal Medicine. Indeed, three out of four American physicians say that ordering an unnecessary test or procedure is commonplace in medical practice and a serious problem — yet they confess to doing it themselves on average once a week.

Why? To mollify patients. Out of habit. Failure to keep abreast of evolving evidence on effectiveness. Fear of malpractice judgments. And because, as the JAMA Internal Medicine editorial suggests, “in the United States, there is a deeply held cultural belief that more health care is better and that earlier is better, beliefs that [have been] strongly reinforced by financial and legal incentives.”

But the ground has shifted. Nationwide, progress is underway to discourage obsolete and useless — if not harmful — interventions. Under the rubric of “less is more,” physicians and hospitals are sharply curtailing antibiotic prescriptions (to counter the dangerous increase in resistant strains) and potentially addictive opioids; limiting patient exposure to diagnostic radiation; shortening in-patient stays with their risk of hospital-acquired infection and physical and mental atrophy; eliminating nonessential screenings that can lead to harmful overtreatment … all while achieving better outcomes at lower costs.

Near Boston, the nonprofit Lown Institute has been a catalyst with its sponsorship of the RightCare Alliance, a nationwide health professional’s network dedicated to “transforming the culture of medicine and building a health care system that is affordable, effective, personal and just.”

With Lown Institute backing, the British medical journal The Lancet last month launched its five-part “Right Care” series — articles investigating worldwide medical underuse and overuse as exemplified by inappropriate knee replacements (34 percent in the United States), inappropriate hysterectomies (20 percent in Taiwan), excessive C-section rates (6.6 million performed without medical justification worldwide) and millions of premature births that could have been prevented by a simple steroid prescription.

For its part, under the rubric “A Teachable Moment,” JAMA Internal Medicine now includes in each issue a detailed analysis of a circumstance in which an ineffectual test or medical procedure was ordered, what best practice counsels instead and why.

Better choices
Prominent in this movement is the Choosing Wisely campaign launched in 2012 by the ABIM Foundation and Consumer Reports, in cooperation with more than 75 medical specialty societies (representing over 1 million doctors, nurses, physical therapists and dentists) and 100 consumer, employer and patient organizations. Each specialty has documented and agreed on a set of interventions that physicians often misapply but should avoid and that their patients should decline.

Spurred by the Choosing Wisely recommendations, many of which have been incorporated into Wikipedia articles, 14 participating U.S. health systems have adopted strategies that have resulted, according to ABIM Foundation Executive Vice President and Chief Operating Officer Daniel Wolfson, in:
• A 36 percent reduction in the use of antibiotics and a 26 percent reduction in Pap smears (by changing the recommended frequency from one year to an evidence-based three years) by physicians at the Group Health Cooperative in Seattle.
• A 73 percent reduction in preoperative CT and MRI tests, and a 42 percent reduction in presurgical lab tests ordered at Los Angeles County Department of Health Services hospitals (the nation’s second-largest medical safety net).
• A 55 percent reduction in antibiotic use at Detroit’s Henry Ford Health System.

“What the Choosing Wisely campaign has done is to increase the conversation about why less is sometimes better,” says Wolfson. “We’ve given people an antidote for thinking we’re talking about rationing or ‘death panels.’

“For hospitals and health systems, Choosing Wisely engages physicians in ways I think quality improvement efforts in the past have not.” he says. “Physicians identify with their own specialty societies, and if they see recommendations from people they trust and respect, they’re more likely to feel ownership rather than that something is being imposed by administration. It’s more of a bottom-up approach.”

Now, he says: “We’ve pivoted from getting awareness and buy-in to turning to institutional implementation. From here on, it’s really up to the delivery systems.”

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.

Original article accessed here.

Audio file at the link below…

https://www.marketplace.org/2017/02/16/world/ambulance-service-texas-delivers-home-care

For more than a decade, John Farris traveled through the streets of Fort Worth, Texas, working 911 calls. As a paramedic for MedStar, he would ask himself: Could he prevent these 911 calls in the first place?

It’s a question that went against the very business model of MedStar until recently — a question most emergency medical services companies don’t talk about, because the more trips to the hospital, the more money the company makes. But it still mattered to Farris. So, sometimes, after stabilizing a patient in the back of the ambulance, he’d try to squeeze in a conversation about nutrition or hydration.

“I’d be lucky if I got 10 minutes to talk with them,” he said.

Now, he gets a full hour with five patients each day.

Traditionally, ambulance crews arrive with sirens blaring, ready to rush someone to the hospital. In Fort Worth, some paramedics are doing the opposite: scheduling visits to treat patients in their homes.

This idea — what’s called mobile integrated health care — is gaining traction as a way for hospitals to save money.

Farris still works for MedStar. He still carries a bag with a CPR kit and gauze and gloves, but he rides in a four-door sedan, not an ambulance. Farris is what’s called a community paramedic.

It’s his job to see the trickiest patients, the so-called “frequent flyers” who keep landing back in the emergency room. Since the Affordable Care Act, the government penalizes hospitals for re-admissions. So these patients are costing hospitals across the country hundreds of millions of dollars. Farris is trying to figure out why they keep returning.

Today’s second stop is at Sandra Guevara’s apartment in Fort Worth. It’s dark, and the black curtains are closed. Guevara, who is in her early 30s, sits on her couch wrapped in a Dallas Cowboys blanket while she gets her blood pressure taken.

Last year, Guevara went to the emergency department more than 20 times, occasionally needing a ventilator to breathe.

“My asthma has been going on since I was 14 years old,” she said. “My anxiety triggers it when I go places, so I tend to shelter myself and stay home all the time.”

Guevara is on Medicaid, so she generally doesn’t have to pay the more than $1,000 each visit might cost. But those visits are something the government, hospitals and especially Guevara want to avoid.

“I don’t like going to the ER,” she said. “Especially when they put me in a little bitty room. I’ll start crying and shaking and everything. I can’t deal with it.”

Farris said from the perspective of the doctor in the emergency room, patients like Guevara can be labeled noncompliant. They’re sometimes seen as patients who won’t follow medical orders. But he said if you spend time getting to understand the situation, that’s not usually the case.

“The mental health needs that [Guevara] has, tied in with her asthma, tied in with her allergic asthma, tied in with her clotting factor, all of this stuff together, even her dehydration, all of it together is combining factors to make her worse.

And every time she was out of the hospital she was back in a couple of days,” Farris said.

He’s helped Guevara modify her diet, convinced her to drink more water and consistently take her medication. He also made sure her doctors know what’s going on and connected her to a psychiatrist. Next visit, they plan to tackle one of her fears and take a short walk outside.

Taking walks with patients, talking to them about their fears, setting up social services like Meals on Wheels, is a major shift in emergency medicine.

When MedStar started enrolling patients for its mobile integrated health care program in 2009, it was one of the first in the country. Today, there are more than 260 similar programs.

Dr. Darrin D’Agostino, associate dean of community medicine at UNT Health Science Center, said early studies show pairing frequent hospital users with community paramedics can save money by preventing re-admissions in the long run.

“Some programs are actually showing decreases of 80 to 90 percent re-admission because the services that are needed are things that are not necessary provided by the physician,” D’Agostino said.

That includes things like making sure a patient has the right medicine — and calling the electricity provider to pay a bill and keep the lights on.
MedStar reports saving $17,000 per patient over a three-year period. The challenge, D’Agostino said, is securing initial funding. Right now, most emergency services are paid for ferrying patients to the hospital.

Since MedStar’s community paramedicine program is paid for by hospitals and health providers trying to save costs, it’s not clear if it would be affected by changes to the Affordable Care Act. The company is counting on a continued focus on the quality of care — and cost-cutting — no matter what happens with the ACA. It just helped publish a textbook on how to provide home care that’s now available nationwide.

NIAGARA — A virtual treasure trove of new health-related data on Niagara residents across their lifespans is expected to play a crucial role in shaping programs and interventions to better combat everything from alarming levels of mental health problems among young people to soaring numbers of 911 medical calls that are straining finite paramedic services.

The massive examination of health data carried out by staff at the region’s public health department over the last 18 months involved scouring nearly 50,000 lines of data from multiple sources covering everything from what drives people to call an ambulance and visit a hospital emergency room, to infectious diseases, behaviour related to chronic disease, and the top things that kill Niagara residents.

Known as the ‘life course’ method of analyzing and visualizing Niagara’s top health issues, the approach marks a major shift in how public health looks at its key mandate of illness and injury prevention, Niagara medical officer of health Dr. Valerie Jaeger told regional politicians on Tuesday.

Rather than tailor programs based on assumptions or best guesses, the wealth of new data should allow the region and the Local Health Integration Network (LHIN) of which Niagara is part to make targeted investments aimed at key factors identified in the new analysis, said Jaeger.

“This is a different way of doing business for us,” she said. “(It’s) becoming more goal-focused. “

Jaeger said she was most interested in the actual health problems affecting Niagara residents at different ages and stages of their lives. “If we know what those are, we should then work backwards to see what programs would best influence them,” she said.

So she tasked her staff with the arduous process of collecting and analyzing the data that will now be presented to the local LHIN, the provincial agency that oversees decision-making on most health care expenditures in Niagara.

Among the more notable data uncovered was that being overweight/obese was the number one self-reported condition for every single age group from kids aged 12 and up to old adults, along with the fact that the top diagnosis for many older people being discharged from hospital is arthrosis — degenerative joint disease often requiring joint surgery or replacement, often the result of being inactive or overweight — highlighting the need to get kids and adults more active when 80 per cent of Niagara residents are sedentary, said Jaeger.

“Overall, it has a huge impact,” she said.

But mental health issues also emerged as a top priority to address. Psychiatric/behaviour problems were found to be among the top reasons for trips in ambulances for kids aged five up to adults aged 44; intentional self-harm was among the top five causes of death among teens aged 15 up to adults aged 44; and mood disorders such as bipolar disorder or depression and anxiety disorders were among the top five self-reported conditions in the 12- to 64-year-old age groups.

“The mental health piece comes up time and time again,” said Jaeger, who noted regional staff are already getting working on a mental health strategy across the age groups in Niagara.

The mental health data was jarring to Pelham Coun. Brian Baty, a former principal who spent his career working with young people.

“The thing that stood out to me is the early onset and prevalence of mental health issues in young people,” he said. “It was striking, but the facts don’t lie.”

Regional Chair Alan Caslin said the region could use the data as ammunition to convince the LHIN to invest in programs and interventions to target problem areas identified.

“You’ve done such a great job in presenting the data in a non-disputable way,” he said. “I think you’ve done all the right things to identify where the problems are. (It’s) remarkable.”

The fact the region has made improving Niagara’s economy a key priority is also important due to data showing people aged 45-64 have high rates of excessive alcohol or illicit drug use in Niagara, said Jaeger. Often, the basis for those problems are a weak economy, and the lack of self-esteem that can be attached to joblessness, she said.

The region has been forced to continue to add new ambulances and paramedic crews to its Emergency Medical Services department in recent years to try to keep 911 call response times at acceptable levels amid rapidly escalating call levels. A consultant hired to explore that issue told regional politicians last fall that massive new investments into the service will be needed in the next decade unless the region can somehow slow down those call increases.

But the new analysis now breaks down the top five reasons for ambulance rides by every age group, something which should help the region to begin bending the curve on EMS calls to hopefully slow the call volume growth by focusing on those factors that cause the most ambulance responses, said Jaeger.

Sinead McElhone, surveillance and evaluation manager at the region who took the lead on the new research, noted that acute upper respiratory infections associated with flu are among the top five diagnoses for everyone from infants up to adults aged 44 at hospital emergency rooms.

That should reinforce the need to double down on efforts to promote prevention strategies such as proper hand washing, she said.

“These are still preventable,” said McElhone. “They’re still the main reason young children are ending up in (emergency) departments.”

Jaeger said it’s believed Niagara’s public health department is the first in the province to be ready to present such detailed data by age group to the LHIN on how the health system is being utilized. Her department is in the midst of assessing what steps could be taken by public health, Niagara Health, which operates local hospitals, or the LHIN in light of the new data.

“We’re looking at transformative opportunities,” said Jaeger, noting there are critical ages in people’s lives when interventions can change health trajectories over the long term.

“If we get this right at a certain stage, we can reduce the impacts of these conditions,” she said.
Pelham Mayor Dave Augustyn joined other regional politicians in heaping praise on the work to collect and analyze the data.

“It will have uses we haven’t even dreamed of yet,” he said.

Jaeger said her staff is willing to present the findings to local town and city councils or service clubs if they’re interested.

Original article can be accessed here.

In January of 2015, the San Bernardino County Fire Department was chosen to conduct one of 13 pilot projects in California aimed at studying the value of community paramedicine.

Community paramedicine (CP) is an innovative model of care services that uses paramedics and emergency medical services (EMS) to treat local patients and meet their health care needs directly in their homes.

For this study, San Bernardino County Fire has partnered with Rialto Fire Department, San Bernardino County Department of Public Health, Arrowhead Regional Medical Center (ARMC), and the Inland Counties Emergency Medical Agency (ICEMA) to provide post-discharge follow-up visits to patients with congestive heart failure (CHF) in Fontana, Hesperia, and Victorville.

“Community paramedicine is the next innovation in healthcare,” said Fire Chief Mark Hartwig. “The goal of this program is to augment the patient’s current plan of care with resources currently established within the community which will provide the patient with the education and tools to maintain and improve wellness outside the hospital.”

The pilot project’s objective is to reach out to CHF patients within the first 48-72 hours of being released from ARMC and improve the quality of life for the patient by decreasing the rate of readmission to the hospital and reducing the need to access 911 for non-emergencies.

A statewide evaluation of the pilot project found that community paramedics identified 129 post-discharge patients (14 percent) who misunderstood how to take their medications or had duplicate medications and were at risk for adverse effects.

The evaluation also found that four of five post-discharge pilot projects achieve cost savings for payers, primarily Medicare and Medi-Cal due to reductions in inpatient readmissions within 30 days of discharge. Hospitals realized savings as well by lowering their risk of being penalized by Medicare for having excess readmissions.

The community paramedicine pilot projects also accumulated savings for parts of the health care system due to fewer ambulance transports, emergency department visits, and hospital readmissions.

Thus far the pilot project has shown that EMS and paramedics can facilitate more appropriate use of emergency care resources and/or enhance access to primary care for medically underserved populations when they function outside their customary role as an emergency transportation service.

In preparation for this project, San Bernardino County Fire specially trained 17 firefighter paramedics in CHF patient assessment, medication reconciliation, laboratory evaluations, and home safety inspections.

State officials have extended the project through November of this year.

San Bernardino County Fire has enrolled 179 post-discharge patients since 2015 and expects to enroll up to 300 before the end of the project.

During a visit, the community paramedics perform a detailed physical assessment on the patient and ensure they are maintaining or improving their post-discharge status. They also will consult with the patient and/or caregiver to ensure the patient understands their condition, is eating properly, and knows how to take prescription medications. Visits also include a home safety check to reduce risk of accidental injury and to avoid potential emergencies.

San Bernardino County is home to one of the largest per capita populations of CHF patients in the U.S. Sufferers of this condition who are unable to properly have their disease managed depend on the emergency medical system (both 911 and emergency departments) to keep their condition in check; community paramedics help address the healthcare needs of this population.

Fort Worth, TX – The National Safety Council is recognizing MedStar for its proven commitment to traf-fic safety.

MedStar is one of four organizations receiving the prestigious Our Driving Concern Texas Employer Traffic Safety Awards, presented in partnership with the Texas Department of Transportation.

“This is our second year to receive a traffic safety award through the “Our Driving Concern” program with the National Safety Council and the Texas Department of Transportation, and the first time we have been recognized with their ‘Exemplary’ distinction. It’s a wonderful recognition of all the efforts MedStar’s team members undertake to help assure our team members and the public are safe while we respond to over 140,000 ambulance calls in our community” explains Shaun Curtis, MedStar’s Safe-ty Manager.

According to the National Highway Traffic Safety Administration (NHTSA), there are an average of 4,500 ambulance crashes annually in the U.S.[1]

MedStar units experience 0.25 crashes per 100,000 miles driven, an exceptionally low rate of ambu-lance crashes given the 2.4 million miles MedStar units log annually!

MedStar’s ambulance operators are certified as Certified Emergency Vehicle Operator (CEVO) and un-dergo continuous ambulance operations training and monitoring through the use of Lytx Drivecam units installed in all response vehicles.

MedStar will be recognized at the National Safety Council Texas Safety Conference & Expo March 5-7 in Fort Worth.

About the National Safety Council
Founded in 1913 and chartered by Congress, the National Safety Council, nsc.org, is a nonprofit organization whose mission is to eliminate preventable deaths at work, in homes and communities and on the road through leadership, research, education and advocacy. NSC advances this mission by partnering with businesses, government agencies, elected officials and the public in areas where we can make the most impact – distracted driving, teen driving, workplace safety, prescription drug overdoses and Safe Communities.

About the Our Driving Concern Texas Employer Traffic Safety Program
The Our Driving Concern Texas Employer Traffic Safety Program is a landmark driving initiative of the National Safety Council funded, in part, by the Texas Department of Transportation. This initiative supports a statewide network of employer involvement in crash prevention for the benefit of employees, both on and off the job. Our Driving Con-cern provides a variety of free resources, training opportunities and educational materials to help employers en-gage their employees in safe driving behaviors. Have a question or a request for your organization? Please contact Lisa Robinson, CFLE, Our Driving Concern program manager, (512) 466-7383.

About MedStar
Responding to over 140,000 calls each year, MedStar Mobile Healthcare is the exclusive emergency and non-emergency ambulance service provider to over 936,000 residents throughout Fort Worth and 14 other Tarrant County cities including Haltom City, Burleson, Saginaw, White Settlement, Forest Hill, River Oaks, Lake Worth, San-som Park, Westworth Village, Blue Mound, Edgecliff Village, Haslet, Lakeside and Westover Hills. Established in 1986, MedStar is governed by the Area Metropolitan Ambulance Authority board of directors, is one of only 132 ambulance services in the country to receive national accreditation by the Commission on Accreditation of Ambu-lance Services. MedStar was named the 2013 Paid EMS Provider of the Year by the National Association of EMTs and EMS World Magazine and is a three time awardee of EMS10 Innovator Awards by the Journal of Emergency Medical Services (JEMS).

Like many hospitals, Sunrise Hospital & Medical Center, Las Vegas was receiving more patients in its emergency department than it was equipped to manage regularly.

One of the largest Medicaid providers in Nevada and situated minutes from the rowdiness of the Las Vegas Strip, Sunrise was struggling with hold hours in its ED. In its worst month, the hospital experienced 28,000 hold hours, with the normal average nearing 20,000 per month, says Alan Keesee, COO, Sunrise Hospital & Medical Center.

Ever since the passage of the Affordable Care Act, and Nevada’s decision to expand Medicaid, Sunrise’s utilization of emergency services has increased double-digits each year. Last year, the Las Vegas hospital received 157,000 ED visits, the largest in the state, by far, says Keesee. With well over half of those visits attributed to Medicaid patients, he added.

Something had to be done to ease the burden on providers. Keesee says leadership saw an opportunity to streamline processes and get patients up to the floors and reduce patients’ length of stay overall.

Sunrise decided to integrate its emergency department and hospital medicine teams into one — unifying them under a single medical director.

The result was a one-team, one culture philosophy, says Keesee. The hospital’s efforts to increase the number of providers through recruitment and the development of team-based models for observational patients and protocols as part of the integration has also helped reduce hold hours.

Whereas most hospitals have their observational patients spread across the facility, Sunrise created a 30-bed observation unit, and dedicated providers and case managers to oversee that unit and monitor results, which has helped increase the number of patients discharged prior to 11 a.m. to 50 percent, up from 10. These measures have also contributed to a one day decline in length of stay for patients.

And not only have those hold hours dropped 79 percent in the ED to 6,000 hours per month, but there has been a palpable change in culture and care. One of the most noticeable changes has come from a nursing standpoint, says Keesee. Nurses now know who is on a team that day, and trust has greatly improved since having a dedicated leadership team focused on shared goals. Nurses will call and text physicians, and are able to know who their doctor is that day, says Keesee. “It’s really increased overall nursing and physician collaboration,” he added.

Keeping the momentum going and avoiding old pitfalls is always a concern after a large integration. Keesee notes that in order to keep pushing forward, leadership needs to come together to continually look for areas to collectively improve.

“You can’t do that in a silo, just the ED, just the hospitalists, you have to really have all those voices at the table, to make the improvements [and] continue to move forward,” says Keesee.

“If you’re disconnected, as an administration, with your medical leadership it’s really hard to move the organization forward with patients.”

Original article can be accessed here.