News & Updates

As physician leaders in North Texas, we have concerning news. Healthcare for the most vulnerable patients in Texas is threatened even more as the likelihood increases that we’ll see less federal funding in the coming years. In 2015, the state of Texas asked the federal government (through the office of the Centers for Medicare/Medicaid, or CMS) for a renewal of a funding model (we know it as the 1115 Waiver) that would have totaled more than $30 billion statewide.

The request was only partially granted. CMS gave Texas 15 months of funding instead of the five years requested; this would reduce our state’s healthcare system funding by more than $20 billion. Time is running out for the state to address some of CMS’ concerns and receive approval for all the funds previously requested, and it does not take a physician to diagnose this as a serious problem. Not making a counteroffer would create a disaster to the already tenuous safety net. And to provide a counteroffer, the physicians of the Dallas County Medical Society, along with community partners, spent the last two years building a model healthcare delivery plan that we believe can solve this very large problem.

We call it the Dallas Choice Plan.

Initiated in 2012, the 1115 Waiver, also called the Texas Healthcare Transformation and Quality Improvement Program, was intended to “redesign healthcare delivery” with an overarching goal to “transform the current delivery of care and payment systems in Texas to a system that is more transparent and accountable.”

While the waiver has incentivized transformation of healthcare delivery in hospitals and healthcare systems that receive CMS funds toward uncompensated care, the waiver has not had a tangible positive impact on the health of the community at large, nor on physicians who provide care for the vulnerable population in our county and state. The Dallas County Medical Society believes the Dallas Choice Plan is a solution that Texas and CMS are looking for, enabling the restoration of the federal government’s funding for the most vulnerable in our county and state.

We are in the process of asking Gov. Greg Abbott, Lt. Gov. Dan Patrick, Speaker Joe Straus, and Texas Health and Human Services Commissioner Charles Smith to look at our plan. We believe it could serve as the next step and the next model of care for communities across Texas after the 1115 Waiver ends next year.

Instead of debating how to reform our local healthcare system, the Dallas Choice Plan proposes a pragmatic and creative solution to address the “access gap” that still impacts about 30 percent of our citizens. Thousands of patients in the gap today are in working families with children. Lack of affordable healthcare for parents and children affects each family’s security and wellbeing, and affects us all through the impact on our businesses, schools, hospitals, and neighborhoods.

Before we share the basics of the Dallas Choice Plan, let’s look at why we need a new model. Dallas is a great city, with great communities and great people. However, Dallas has its blemishes. Although our healthcare industry exists under a free-market economy, today’s crushing, competitive environment among Dallas’ large hospital systems diverts attention from effective planning and execution of community-based health delivery solutions for vulnerable populations.

As hospital systems continue to use profits and federal funds for competitive advantage, they minimize investments in prevention and before-hospital healthcare, placing at risk those vulnerable patients who could benefit from such services. Hospitals clearly hold the largest share of resources and carry the greatest influence toward supporting community-wide solutions. Yet currently, none of the federal funds go toward covering costs for healthcare provided by independent private physicians; this seriously limits non-hospital access to physician services for vulnerable patients.

Here are two simple examples of the unfortunate outcomes of the competitive landscape among our Dallas hospitals. While no patient prefers waiting in a crowded emergency room to treat an issue that could be managed in a doctor’s office, the waiver funds rarely are used to address this concern. Further, no one wants a second or third MRI test simply because our hospitals do not want to share information among themselves.

As Matt Goodman wrote in D Healthcare Daily on Sept. 8, 2016, the federal government has provided more than $3 billion directly to hospitals in North Texas over the last five years through 1115 Waiver funding. Instead of using these funds to transform the system, we argue that we have seen what could be described as a “medical arms race” in hospital facility construction. This surge of hospital construction has targeted the more affluent (and insured) areas of North Dallas, not the needier areas in southern and western Dallas County. This is contrary to the purpose for which we believe these funds were earmarked—to address the unmet needs of thousands of people without health insurance or unable to pay for health care themselves.

The 1115 Waiver Community Needs Assessment Task Force in 2012 listed “Primary and Specialty Care Capacity” as the region’s top community healthcare priorities, stating that “demand exceeds available medical physicians in these areas, thus limiting healthcare access.” Because 1115 Waiver funds flowed entirely into Dallas hospitals, we believe these funds have not been used to their full potential to help solve the decades-long problem of unequal access to primary and specialty physician health care for vulnerable people in Dallas.

As an alternative, the heart of the Dallas Choice Plan is a true Community-based Accountable Care Organization (ACO). A Community ACO is a new term for a healthcare organization that includes physicians, hospitals, and other health providers to care for a population of people. The organization is transparent with regard to performance of its provider network in relation to costs and quality. All health providers in a Community ACO must meet quality and efficiency standards within budget. This is just what the doctors are ordering for Dallas’ solution to this vexing access problem.

The Dallas Choice Plan would rely on Parkland Health and Hospital System’s support and leadership to anchor the Community ACO. Just as the community strongly supported building Parkland’s state-of-the-art hospital facility, we see a great opportunity for Parkland to be supported in this new role. Physicians in North Texas have a strong connection to Parkland, as most of us either trained or worked at this great institution during our careers. This trusted community health system could be the foundation that recruits private hospitals and independent physicians, along with community clinics and a host of other community-based health providers, thereby further strengthening Dallas’ healthcare safety net.

The Dallas Choice Plan is transparent, accountable, and transformative in its emphasis on real and meaningful access to care. It was designed by many of our long-time partners in the Dallas community who care deeply about vulnerable patients. We long ago reached out to Dr. Fred Cerise, CEO of Parkland Health and Hospital System, and his team; they agree with many of our ideas and have expressed an interest in working with us on this. Certainly, much work needs to be done, but let’s be sure to create a model that supports everyone who is serving this patient population. Let’s not waste one more dollar on competing hospital systems.

We propose to test this model in Dallas County, and if successful, believe it could be effective in other areas of Texas. But to even test the model, we need state leaders and CMS to agree to try.

As leaders of the Dallas County Medical Society for the past three decades, we believe our state, our county and our patients need a viable alternative now.

Original Article can be accessed here.

The former Coalition of Advanced Emergency Medical Systems (CAEMS) is now The Academy of International Mobile Healthcare Integration (AIMHI). This rebranding demonstrates high performance EMS systems’ focus to highlight the rapidly transforming role of EMS agencies across the United States and Canada. This first of its kind webinar will introduce the participants to AIMHI and its mission, and explain the concepts of High Performance EMS (HPEMS).

About the Presenters
Douglas Hooten
CEO
MedStar Mobile Healthcare

Doug Hooten is the Chief Executive Officer of MedStar Mobile Healthcare in Fort Worth, Texas. He has over 35 years of experience in EMS, having served as senior vice president of operations and regional director for American Medical Response, CEO of the Metropolitan Ambulance Service Trust (MAST) in Kansas City, and a variety of leadership roles with Rural/Metro Ambulance, Inc. in South Carolina, Georgia, Ohio and Texas. He has demonstrated considerable expertise in change management, cost optimization, process improvement and clinical excellence.

Having started his career in EMS as a field paramedic in Conroe, Texas, Hooten holds an undergraduate degree in business administration from Sam Houston State University in Huntsville, Texas and a Master of Business Administration from Rockhurst University in Kansas City, Missouri. He serves on the National EMS Advisory Committee (NEMSAC), and is the president of the Academy of International Mobile Healthcare Integration. Doug is also a Board Member for the American Ambulance Association and the Texas EMS Alliance.

An expert in Mobile Integrated Healthcare, Doug is a co-author of the Jones and Bartlett book “Mobile Integrated Healthcare – Approach to Implementation” and is a regular speaker for industry conferences.

Jonathan D. Washko, MBA, NREMT-P, AEMD
Assistant Vice President
Northwell Health – Center for EMS

Jonathan Washko as been involved in the EMS industry for over 30 years and has held progressive leadership position with small, medium and large EMS systems in government, private, for-profit and not-for-profit entities. Mr. Washko is considered the leading industry expert on EMS system design, High Performance EMS concepts, Industry Best Practices, EMS Deployment, Lean Business Processes, System Status Management and EMS Finance and is often called upon by EMS systems in crisis as well as those considered at the top of their game, in order to help transform these organizations to become the best they can be. Mr. Washko frequently speaks at national conferences, sits on various industry boards, consults on an international basis and currently serves as the Assistant Vice President of Operations with Northwell Health Center for EMS.

Kevin Smith
Chief
Niagara Emergency Medical Services

Kevin Smith started his career as a paramedic in Niagara after graduating from Niagara College in 1992 and going on to receive his Advanced Care Paramedic designation from the Michener Institute, Toronto in 1998. Receiving his Bachelors of Applied Business in Emergency Services degree in 2010, Kevin has worked through various levels of the profession to his current position as chief of Niagara Emergency Medical Services. Kevin is responsible for providing emergency services to the 12 local municipalities that make up the Niagara Region comprising a population of over 425,000 residents as well as over 2.5 million visitors to Niagara per year. He oversees a department budget of more than $40 million including the portfolios of land ambulance, dispatch (ACE), regional emergency preparedness, regional fire coordination, and regional 911 services. Kevin leads a team of more than 340 advanced and primary care paramedics, emergency medical dispatchers, emergency planners and administrative staff and his team handles 90,000 calls per year with over 50,000 patients transported to local hospitals. Kevin is active in national, provincial and regional paramedic organizations and currently leads the Paramedic Chiefs of Canada (PCC) in strategic planning, receiving the PCC President’s Award in 2016.

Introduction to AIMHI and The New Role of High Performance / High Value EMS – Part 1
October 19, 2016
12:00 pm EST.

REGISTER NOW

Thank you to our webinar provider, FirstWatch

September 28, 2016

Kenneth W. Kizer, M.D., was a firefighter when paramedicine was emerging in the Los Angeles area and, as director of California Emergency Medical Services Authority in 1983, he wrote the regulations for paramedicine in the state. Now he is a thought leader in population health — and an advocate for community paramedicine in value-based care.

You have defined community paramedicine (CP) as “a new and evolving method of community-based health care in which paramedics function outside their customary emergency response and transport roles in ways that facilitate more appropriate use of resources and/or enhance access to primary care for underserved populations.” What is the state of CP currently?

KIZER: I’ve seen paramedicine evolve from its earliest days to where it is now, and I think community paramedicine is perhaps the next big evolution for paramedicine.

There are programs in varying stages of development in more than 20 states and more than 150 communities. The programs are spreading pretty rapidly, and I think they will continue to do so.

Community paramedicine is an important component of population health management and the new emerging value-based health care economy because it fills gaps in the typical health care delivery infrastructure that are especially relevant to value-based payment.

The focus of CP programs varies widely — from paramedics providing directly observed treatment for tuberculosis patients at their homes to providing transportation to health care facilities other than emergency departments and many other concepts.

What do you consider to be the most promising applications for CP?

KIZER: The programs that respond to the 9-1-1 superusers hold a lot of promise for better utilizing scarce emergency care resources, including ambulances and hospital emergency departments. We know that in many communities some people call 9-1-1 multiple times per week when what they really need is help with basic primary care or other support services. Many of these persons may be homeless or have mental health needs or other problems that are not always better managed in the ED.

Another type of program that I think is going to prove to be very helpful is one that provides follow-up care after a hospital discharge or an ED discharge. These programs serve patients before they can get in to see their usual provider or — probably more often — until they can establish a relationship with a regular health care provider.

I also think CP programs that provide in-home care for frail elderly persons who have multiple chronic conditions and may have limited mobility are going to be quite successful. These patients may have cognitive issues that impair their ability to comply with medication or other treatment regimens. They may lack transportation. And too often their only resource is to call 9-1-1 and take an ambulance to the hospital ED, when their needs could be much more economically and effectively — and I would argue, compassionately — dealt with by paramedics who come in to help them with their medications or wound care or whatever their individual needs may be at the moment.

Despite its obvious merits, telemedicine has been slow to gain widespread adoption until recently. Do you expect CP to have a similar slow path to reaching its potential?

KIZER: Community paramedicine shares many of the same barriers and challenges that telemedicine does, although it has some things working to its advantage that I think will speed up its widespread implementation.

For many providers and patients, telemedicine is a really new way of delivering or receiving care and it requires the provider to buy new technology, which people then have to become familiar with. By contrast, paramedics are an already existing and very large workforce that is well-integrated into local communities and very well-trusted and highly regarded by the public. Another advantage that CP has is the rapid evolution to a value-based economy in which it can fill a clear and demonstrated need. CP provides a bridge between primary care and emergency care and can fill gaps in the underlying health care delivery infrastructure that exist in so many communities across the country.

One of the barriers for the widespread adoption of community paramedicine is the limited data about safety, efficacy and long-term outcomes. Many different models of community paramedicine have arisen independent of each other to address particular local needs. As a result, there is a lot of variability in exactly what CP programs do, so it is difficult to compare outcomes from one program with outcomes from another — or to combine data from different programs to analyze CP in the aggregate. Various programs have demonstrated they have reduced 9-1-1 calls, ED visits, hospital admissions and readmissions, and emergency transport charges, but those data are not as compelling as what either Medicare or other health care payers generally want to see before they decide whether they’re going to cover a new service.

And that leads to another barrier — reimbursement for services — that CP shares with telemedicine. Most of the CP programs to date have been developed out of grant monies or other short-term funding. And some of the programs have closed shop because they were not economically viable in the long term. The interrelated problems of outcomes data and reimbursement have to be addressed for CP to move forward.

In response to a recommendation from your report — “Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care” — California authorized several CP pilots. What is the purpose of these pilots?

KIZER: In California and a few other states, paramedics’ scope of practice is defined both by what they do and where they do it, unlike most other health care workers for which the scope of practice is just what they do. Our recommendation was that the state needed to do pilots to establish safety, efficacy and outcomes data as a basis for changing the state laws to permit community paramedicine.

There are 12 pilots underway. The largest number of those have paramedics providing transportation to destinations other than a hospital ED, such as a mental health clinic, an urgent care clinic, a doctor’s office or a sobriety center.

Another group of pilots allows paramedics to provide follow-up care after an ED or a hospital discharge.

Other pilots are experimenting with different models of community paramedicine. The pilots are still underway, and an assessment should be completed in 2017.

How does CP fit into the current health care delivery system?

KIZER: Emergency medical services are clearly a well-established and essential part of the health care delivery system, but are often viewed as outside of the usual care delivery system. Many physicians who don’t interface with the emergency care system don’t really understand paramedics or how the pre-hospital care system works.

Physicians and health system leaders need to see CP as a very promising model of community-based care that can help to support their population health management goals and their clinical integration goals and help them to thrive in a value-based health care economy.

Original article can be accessed here.

There’s a revolution taking place in emergency medical services, and for many, it could be life changing.

From the increasingly sophisticated equipment they carry and the new lifesaving techniques they use, to the changing roles they play in some communities—providing preventive care and monitoring patients at home—ambulance crews today are hardly recognizable from their origins as “horizontal taxicabs.”

Here’s a look at some of the most important changes happening in EMS care around the country—including a few plans in the testing phase still, and the challenges EMS professionals face to bring those to reality.

In case of emergency …

EMS crews today are better equipped than ever for the worst kinds of emergencies, from cardiac arrests and gunshot victims to car crashes and other life-threatening injuries. These days, more ground and air ambulances include X-ray and ultrasound devices, machines that perform automatic chest compressions for CPR, communications systems that forward electrocardiograms to the emergency room, and equipment for lab tests that can identify dangerous conditions such as a developing septic infection.

Much of the best equipment—including a helicopter equipped as a mobile emergency room or intensive-care unit—can be found at the Mayo Clinic, in Rochester, Minn. Regarded as a leader in sophisticated onboard equipment and communications, Mayo often consults with other medical transport systems to share best patient care strategies, and works with U.S. military physicians to share expertise on how treatment of battlefield wounds might apply to civilian medicine.

Mayo provides increasingly advanced pre-hospital treatment, saysScott Zietlow, a trauma surgeon and medical director of the Mayo One trauma helicopter program. External defibrillators and pacemakers are standard, as are portable analyzers for lab tests and noninvasive devices to determine if a blood transfusion or antibiotics are needed. Because Mayo has its own blood banks, its air ambulances are able to provide a growing array of blood products that most others don’t carry.

In addition to featuring state-of-the-art equipment, Mayo’s emergency medical service has helped test a number of EMS innovations, including capnography, a monitoring device that helps in the placement of breathing tubes and measures the concentration of carbon dioxide in exhaled air. This can guide the effectiveness of CPR chest compressions and gauge the likelihood that a patient can be revived. Mayo Clinic can also transport patients on a machine that does the work of a heart and lungs.

Mayo’s work with the military has led its EMS crews to adopt quick-clotting bandages and tourniquets for blunt trauma and penetrating wounds. A study of 125 patients that Dr. Zietlow co-wrote, published last year in the Journal of Special Operations Medicine, concluded that civilian use of tourniquets and hemostatic gauze is highly effective at stopping bleeding.

Mayo EMS crews also plan to adopt a practice the military uses as an alternative to intravenous lines, particularly when a limb has been lost: sternal intraosseous infusion, in which fluids and medications are administered into the bone marrow directly through the sternum.

Coming soon: preventive-care teams

In what could amount to a sea change for many EMS workers, health-care policy makers are looking at having so-called community paramedicine teams provide preventive care—and even make regularly scheduled house calls.

In a concept some are calling “EMS 3.0,” ambulance crews with advanced medical training in more communities already are treating patients in their homes, including frail or elderly patients, helping to manage chronic conditions like diabetes, and are checking on recently discharged hospital patients to ensure they are following their care instructions.

“We are a natural provider of care outside of hospitals and other institutions,” says Kevin McGinnis, program manager, community paramedicine, mobile integrated health care and rural emergency care for the National Association of State EMS Officials. “The majority of calls that go through 911 are nonemergencies, and we can use EMS resources to address otherwise unaddressed health needs in communities,” Mr. McGinnis says.

Among the nonemergency calls that paramedics often respond to: shortness of breath, weakness and fatigue from dehydration, cuts and abrasions, abdominal pain, low-grade fevers, cold-like symptoms, urinary problems and minor falls in the home.

Dovetailing with efforts to align EMS workers more closely with core health-care delivery, EMS organizations in a draft report released last month called for “an EMS system that maximizes value to the community by providing new and essential services.” Extending EMS responsibilities to helping people navigate the health-care system, coordinating care and better educating patients, the report said, can “ultimately lower cost and improve the quality of patient care.”

The report cited big hurdles, including a highly fragmented national EMS system and payment policies which generally reimburse EMS providers only when they transport patients to a hospital. That could change as private insurance companies and the federal Medicare and Medicaid programs continue in their transition from a fee-for service model to one linked to the quality of care provided and measurable patient outcomes.

According to a 2013 study in the journal Health Affairs, if Medicare would reimburse EMS for services other than transporting patients to an ER, it would improve the continuity of care and save the federal government as much as $560 million a year. If private insurance companies followed suit, the study added, overall savings could be twice as large. The Centers for Medicare and Medicaid Services is now funding several programs testing new models that would reimburse for such alternative models.

Many EMS services are financially strapped due to the hospital-transport-only reimbursement policy, says Kevin Munjal, director of prehospital care at the Mount Sinai Health System in New York. In smaller communities and rural areas, the model is too low-volume to support paid staff, so EMS is provided by volunteers. That, in turn, puts their ability to respond in a true emergency at risk.

By creating a system that reimburses EMS professionals to do things like treat patients at home, move them to other health-care providers and check on them after they leave the hospital, “we could unleash innovative new models of care that meet unmet needs, while making emergency response more reliable,” says Dr. Munjal, who is leading a nationwide EMS innovation project. Otherwise, he warns, “many would argue that EMS’s ability to be there in emergencies is under threat.”

Treating more patients at home

Meanwhile, several pilot programs are working on ambulance services whose job is to not take people to the hospital.

Mount Sinai and a local ambulance company have established a community paramedicine program in which specially trained paramedics respond to calls from patients enrolled in the program or in Mount Sinai’s visiting doctors program. The paramedics visit and examine the patients in their homes, and consult with doctors at the hospital via telemedicine, or two-way video, on what to do next. Out of 36 patients who called the service over a six-month period, only five were transported to the hospital, for an estimated savings of about $1,400 per encounter, Dr. Munjal says. The pilot program was started with a grant from the Centers for Medicare and Medicaid Services and is supported by private foundations.

In a similar pilot program in Mesa, Ariz., dispatchers in the Mesa Fire and Medical Department talk to patients who call the 911 center. For many whose problems are not deemed an emergency, nurses offer medical advice, or send a community-medicine unit to the caller’s home. The units include firefighter paramedics, nurse practitioners or physician assistants, or behavioral-health counselors from local fire departments and health-care providers and a hospital. A test of 983 patient encounters from August 2012 to February 2013 showed a cost savings of over $1 million, according to Mesa Deputy Chief Steven Ward. In 2014, the Mesa program also received a grant from the Centers for Medicare and Medicaid Services.

Caring for patients at home has advantages for everyone—when it’s possible. Tony Lo Giudice, the Mesa department’s community-care grant administrator, says that out of 55,000 calls a year, about 40% are low-acuity, “and it can be can be very expensive to place everyone in an ambulance and take them to the ER.” The community-care units also visit some hospital patients after discharge that are at higher risk of being readmitted, to offer preventive-care measures and make sure the patients are following discharge instructions. Paramedics are then able to identify those that might need follow-up services such as a social worker or physician referral, says Mr. Lo Giudice.

Susie Jackson, who lived in Gilbert, Ariz., says the community unit was a big help when her mother, Nancy Long, 80, cut her arm badly. Ms. Jackson called 911 and jumped in her car to get to her mother, expecting to spend the day in the ER with her. Instead, a physician assistant with the community-care unit stitched up the wound in her mother’s home. “It put my mother at so much ease that she didn’t have to leave home to be taken care of,” says Ms. Jackson.

A national emergency network

New information systems under development could make it far easier to share information in an emergency. First responders currently rely on thousands of separate and incompatible networks during emergencies, and often can’t easily communicate and work together. A 2012 federal law created the First Responder Network Authority, known as FirstNet, an independent authority that is developing a high-speed, nationwide, wireless broadband network dedicated to public safety. EMS teams would be able to transmit live video and images from car crash scenes, for example, even in rural areas with limited coverage.

In another national effort, known as Next Generation 911, states are upgrading antiquated 911 systems, which can only receive phone calls, allowing callers to send video and pictures to dispatchers. A growing number of states have recently added 911 text messaging.

With such advances and mobile apps designed for EMS services, first responders could use smartphones to share information that is now often lost or incomplete when they hand over patients at the ER, saysBenjamin Schooley, an assistant professor of integrated information systems at the University of South Carolina. His design of a mobile system that allows paramedics to transmit video, pictures and other information to hospitals from car crashes has been tested in Idaho and Montana.

So far, Dr. Schooley says, EMS has only started to scratch the surface of what it can do with patient data in real time.

When less care is more

Counterintuitively, perhaps, researchers are finding that some patients may benefit from less intervention by paramedics. Studies have shown that in cases of penetrating trauma, such as gunshot or stab wounds in the torso, chest, abdomen or upper arms of legs, so-called advanced life support methods including providing IV fluids and inserting breathing tubes don’t improve survival rates.

Ambulance crews around the country are using new techniques and testing new missions.

PHOTO: ISTOCKPHOTO/GETTY IMAGES

Temple University Hospital in Philadelphia is embarking on a five-year study that will randomly group patients who are shot or stabbed. One group will receive advanced life support. The other group will be brought immediately to the hospital with only basic life-support therapy such as an oxygen mask if needed. The hospital has been meeting with city residents to explain the study and provide wristbands for those who want to opt out.

Zoe Maher, a trauma surgeon and researcher for the study, says that while the procedures can help in rural areas where trips to the hospital are long, in a city they might not help—and could hurt patients who are shot or stabbed and bleeding to death. For example, administering IV fluids can dilute the blood’s clotting ability, and putting a tube down the victim’s throat can increase pressure in the chest cavity and decrease the amount of blood coming back to the heart.

“Sometimes we think of innovation as adding more treatment, but innovation here means doing less,” says Amy Goldberg, chair of Temple’s department of surgery. “We need to embrace this just as we would a new device or a new technology.”

Ms. Landro, a Wall Street Journal assistant managing editor, writes the Informed Patient column. Email: laura.landro@wsj.com.

Original article can be accessed here.

September 2016

If there is one issue confronting our health-care system on which just about everyone agrees, it’s this: Unnecessary emergency room visits are a significant driver of costs. But getting the people who most abuse emergency services under control has been an uphill battle.

Now a new approach is showing promise in reducing visits to the ER by what the Centers for Medicare and Medicaid Services calls “super-utilizers,” typically defined as those who use emergency services four or more times a year. The National Conference of State Legislatures estimates that up to 27 percent of all visits to ERs are for nonemergencies. But so-called community paramedic programs are finding new ways to manage these frequent flyers.

Minnesota has been a pioneer in community paramedicine. Under its program, a hospital will typically identify four or five super-utilizers who need a managed care approach. Then community paramedics will go into those people’s homes to look not only at their overall health issues but also at factors like safety precautions and nutrition. Through the program, Minnesota has seen ER use by super-utilizers decrease by 60 to 70 percent.

Community paramedics are generally more seasoned emergency medical services personnel who have undergone training to help them identify community-based health needs. “We’re not asking them to do a brain transplant,” says Jim Dunford, the EMS director for San Diego, which has a community paramedicine program that’s part of a state-launched pilot covering nine cities. “The majority of issues that confound our health-care system are social ones. We need to be teaching our patients to connect the dots.”

San Diego’s program uses data to help determine whether a community paramedic should show up at a scene where 911 has been called. “All of the data that resides in these 911 systems gives us the ability to identify individuals who have been using services in the last week, the last six months, the last year,” says Dunford. “We can look at factors like: Do they have co-occurring illnesses? Are they over 65?”

Some of the big insurance players involved with government health-care programs are starting to get in on the action as well. Blue Cross and Blue Shield of New Mexico has begun pilot programs for its Medicaid patients in a few of the state’s more urban areas. The company says a group of patients identified in one of the programs has cut its ER use by 60 percent. One former super-utilizer hasn’t been to the ER in the 11 months he’s been enrolled in the program, says Kerry Clear, the company’s manager of community social services.

In setting up its program, Minnesota included legislation that allows the state’s Medicaid program to reimburse community paramedic services. But most of these programs are either subsidized by ambulance companies operating under fixed-price contracts or funded by grants from foundations or the federal government. In San Diego, whose program is funded through an ambulance service, Dunford is optimistic that the results from the pilot will encourage lawmakers in Sacramento to follow Minnesota’s lead.

The success of the community paramedic model has many EMS directors encouraged that this could be the future of emergency care. On the federal level, U.S. Sen. Al Franken of Minnesota has introduced legislation advocating for community paramedicine nationwide. That’s an idea that appeals to people like Clear. With the number of primary-care physicians at an all-time low, he says, “we all know prevention is key to keeping our communities healthy.”

Original article can be accessed here.

September 17th, 2016

If unnecessary hospital readmissions are, as some suggest, the low-hanging fruit in the pursuit of better healthcare, hospitals should get ready to pluck less and less.

Hospital administrators have had years—four since Medicare’s Hospital Readmissions Reduction Program took effect, and six since the Affordable Care Act spurred a slew of other initiatives to improve healthcare value—to scrutinize and cut down on unnecessary readmissions. And in those years, the U.S. has largely managed to do so, new numbers from the CMS show.

From 2010 to 2015, readmission rates among Medicare beneficiaries fell in Washington, D.C., and every state but one, the CMS reported. That drop translates to about 565,000 avoided readmissions for Medicare beneficiaries since 2010, including 100,000 in 2015 alone.

That momentum could soon slow. That’s not necessarily a bad sign, because not all readmissions are preventable. But it also means hospitals and other providers will have to work smarter to keep making progress on readmissions.

A bevy of CMS initiatives have taken aim at improving healthcare quality while holding down or even trimming costs, with the ambition of tying 90% of traditional Medicare payments to quality or value by 2018. Unnecessary hospital readmissions, regarded as an indicator of poor quality care, play a burgeoning role.

The idea that hospitals can avoid readmissions by providing better follow-up care once patients are discharged is at the heart of the Hospital Readmissions Reduction Program. Under it, those that fail to curb excess readmissions lose out on a portion of their Medicare reimbursements.

The program took effect Oct. 1, 2012, and has imposed increasingly hefty financial penalties on hospitals whose avoidable 30-day readmission rates for a limited list of conditions exceed the national average. For fiscal 2017, which starts Oct. 1, the CMS will penalize more than 2,500 hospitals, saving the agency about $538 million.

Readmissions targeted by the Medicare program are for a narrower set of conditions than the 30-day all-condition hospital readmission rates published by the CMS last week, but the CMS said the program was one factor in reducing avoidable readmissions.

But some providers and policy experts are concerned that imposing financial penalties to drive down excess readmissions could move hospitals to take measures that go too far.

“I think we’re going to reach a point of diminishing return, where to reduce readmissions further is eventually going to be perceived as underdelivering care and almost being cruel,” said Dr. Martha Radford, chief quality officer at NYU Langone Medical Center in New York. “Not all readmissions are preventable, and it’s kind of tough to know which ones are and which ones aren’t, particularly in advance.”

Hospitals can still do more to reduce the unnecessary ones, said Dr. Eric Coleman, a professor at the University of Colorado, where he also heads the healthcare policy and research division. “But the relative return on investment going forward will be less,” Coleman said.

Medicare views hospital readmission rates as an important indicator of the quality of care because they reflect the breadth and depth of care a patient receives. If hospitals fail to treat a patient fully or ensure that the patient has a feasible discharge plan, that patient could end up coming back to the hospital for care. Unnecessary readmissions are also expensive, costing the U.S. $25 billion annually, by one estimate.

More tightly coordinated care and better communication between hospitals and post-acute providers have indeed helped hospitals prevent readmissions and improve the quality of patient care, Coleman said.

“This is a fairly dynamic process, where we believe that what we’re doing is reducing modifiable risk,” Coleman said. But, he warned, “There certainly are people whose risk may not be so modifiable. They really do need to be readmitted. We don’t want to deny care on that end.”

One unintended consequence of Medicare’s focus on readmissions, according to some critics, is that hospitals are keeping patients in outpatient observation status rather than admitting them.

“It has been the case that the hospitals have been gaming the system in extraordinary ways,” said Ross Koppel, a sociology professor at the University of Pennsylvania who conducts healthcare research.

A Wall Street Journal analysis of Medicare billing data late last year concluded that hospitals were indeed gaming the system by classifying patients as being on observation status. Two months later, HHS researchers countered in the New England Journal of Medicine that the small increase in observation claims couldn’t explain a more substantial drop in readmissions.

Providers and their advocates argue that it’s often better for patients to be held for observation rather than admitted. “Observation status helps ensure that the most appropriate setting of care is where the patient ultimately receives their care,” said Lorraine Ryan, senior vice president of legal, regulatory and professional affairs at the Greater New York Hospital Association. It gives a provider more time to evaluate patients before deciding if they should be formally admitted.

And other challenges remain. Despite the progress by hospitals and post-acute care providers, the quality of care that patients receive after they’re discharged still leaves much to be desired. Improving it will require grappling with thorny issues such as insurance coverage and weak healthcare infrastructure in many parts of the U.S.

The reasons for gaps in care as patient’s transition out of the hospital and back home vary from the financial and logistical to the socio-demographic.

Some hospitals, especially safety net providers, care for disproportionate numbers of lower-income patients who live in communities without other healthcare services and resources essential for follow-up care, such as primary-care physicians and pharmacies. As a result, no matter what the hospital does, some patients might not be able to get the follow-up care they need.

“The strategies that hospitals are using, a lot of them are some of the same,” said Akin Demehin, director of policy for the American Hospital Association. “But certainly the challenges that they may face in their own patient population, in their own communities, in their own space, could look a little bit different.”

In other cases, patients or families are given instructions for care after discharge. But that doesn’t mean they can, or will, follow them.

“A lot of folks go home and just feel unprepared and start to panic,” Coleman said. Preventing avoidable readmissions “really is about preparing patients and families to be able to feel confident in their own self-care.”

And sometimes, a patient’s insurance will not cover the post-acute care services he or she needs, or will pay for only a portion.

“We’ve tried a lot of things—we make sure people have a follow-up appointment, we do arrange for visiting nurses, we’ll place them in some sort of chronic-care facility if possible. Often, it’s not,” said Radford, of NYU Langone. “The payment models don’t help here. Some people don’t have coverage for that type of thing.”

Of the 49 states where readmissions fell from 2010 to 2015, 43 saw decreases of more than 5%, and rates fell by more than 10% in 11 states. The one state where Medicare’s 30-day, all-condition hospital readmission rate rose was Vermont—from 15.3% in 2010 to 15.4% in 2015, which the CMS described as “virtually unchanged.”

And according to hospital leaders there, the state may be seeing what others throughout the country are about to experience: doing well on readmissions means lower rates of improvement.

“While Vermont’s readmission rates may not have changed drastically, they remain lower than in more than half of other states,” said Jeffrey Tieman, CEO of the Vermont Association of Hospitals and Health Systems. The state’s rate in 2010 was 1.3 percentage points below the median, according to CMS data.

“Our hospitals recognize that it can be hard to make progress on these types of measures when your state is already a strong performer,” Tieman said. “But they are focused on continuing to reduce readmissions even further by improving the way we coordinate and integrate care.”

Original article can be accessed here.

Cathy Hostettler is a Doctor of Nursing Practice candidate at the University of Kansas.

She did her Doctoral Thesis on EMS-Based MIH programs and their impact on readmissions.  She came to MedStar and did an analysis of our MIH programs and data, specifically as it relates to readmission prevention.

She has presented this paper to the doctoral review panel at the University of Kansas as partial fulfillment of her Doctor of Nursing Practice degree and has given us permission to share it widely …

Cathy did a nice job on this paper and it contains great published references about MIH-CP type programs in the U.S. and abroad…

Univ of Kansas Report on MedStar’s MIH Program Impact on Readmissions

Citation for use:

Hostettler, C. (2016). Mobile integrated healthcare: A program to reduce readmissions for heart failure (Doctoral project). University of Kansas, Lawrence, KS.

Reno, Nev.—Renown Health and the Regional Emergency Medical Services Authority (REMSA) have announced an innovative new alliance to improve the overall health of the region through a proactive system of healthcare services focused on doing the most good for the most people at the least amount of cost.

These Community Health Programs deliver healthcare services and focus primarily on reducing out of pocket costs and unnecessary use of the healthcare system while strengthening the quality and coordination of care and expanding access to the right level of care.

At the center of this alliance are three leading-edge programs: the Nurse Health Line, Community Paramedicine and the Ambulance Transport Alternative. The three programs comprise the REMSA Community Health Programs and were launched in 2012 through a three-year, $9.8 million Centers for Medicare and Medicaid Services Healthcare Innovation Award. Preliminary outcomes from the Community Health Programs show that they continue to facilitate healthcare access and reduce costs with more than 6,200 emergency room visits avoided, over 1,000 ambulance transports avoided and more than $9.6 million in savings to patients and the healthcare system.

After receiving an extension for a fourth year under the current funding amount, the program’s grant funding concluded this past summer. Going forward, thanks to this new alliance, the three programs will be financially supported by Renown. This is an unprecedented partnership based on a commitment from Renown, the region’s largest integrated health network, to REMSA, the region’s largest integrated emergency medical services provider.

REMSA predicts that continuing these innovative programs will have an economic impact of $1.6 million over the next year through savings to the community. By minimizing and avoiding costly ways of accessing healthcare such as unnecessary emergency room visits, hospital admissions, hospital readmissions and ambulance transports, there is more opportunity to provide proactive and necessary healthcare.

“These programs are vital to creating healthy communities by giving people access to services they might otherwise not know how to access,” said Dean Dow, president and CEO of REMSA. “Renown’s commitment to this partnership allows all three programs to continue and for the Nurse Health Line to be available to all citizens in the region.”

The formation of this relationship ensures that these pioneering programs will transition from being shorter-term, grant-funded innovations to comprehensive and lasting systems built to optimize the health of many people in the region. With the aligned goal of promoting health by expanding access to the right level of healthcare at the right time, these programs reinforce Renown’s and REMSA’s work to improve the overall health of the community.

Improving health across the region by strategically and proactively managing clinical and financial opportunities is a key outcome of partnerships like this. Population health management delivers care in a proactive system focused on making care better, more efficient and more cost-effective.  The Community Health Programs are an example of how delivering care that is managed and measured at the population level can lead to longevity, quality of life, and an increase in delivering care in to populations that need it most, thereby improving the health of people with undermanaged conditions and shifting the focus to prevention and wellness efforts.

“Renown is committed to improving the health of the community, which means more than just providing quality healthcare,” said Anthony D. Slonim, MD, DrPH, president and CEO of Renown Health. “It means going outside the hospital walls, offering programs and services that make a lasting difference in the health and well-being of families throughout our region. This can only be accomplished through collaboration with partners who share the vision of a healthier northern Nevada – partners like REMSA.”

REMSA is successfully achieving long-term financial sustainability for these programs through partnerships like this. REMSA is working with a growing number of partners and insurers to develop ongoing support for these new services.

“The emerging data indicates these programs are having a significant positive effect on the health of the community, especially in underserved neighborhoods,” said Kitty Jung, Chair, Washoe County District Board of Health and Chair, Washoe County Commission. “The Washoe County Health District applauds Renown and REMSA for creating this strategic partnership addressing the healthcare needs of our region.”

Since the Community Health Programs launched in 2012, a variety of community partners contributed to their success including hospitals, clinics, fire services, EMS oversight entities, urgent cares, health centers, and non-profit and community groups.

About REMSA

REMSA is a private, locally governed, non-profit emergency medical services provider serving northern Nevada since 1986. REMSA also comprises Care Flight, a regional, non-profit, air and ground critical care transport service, a Nevada-licensed, post-secondary educational institution, a state-of-the-art, fully accredited 9-1-1 dispatch communications center, a Tactical Emergency Medical Support team and community and special events EMS teams. REMSA provides quality patient care with no taxpayer support or other subsidies. For more information, visit remsahealth.com.

About Renown Health

Renown Health is a locally governed and locally owned, not-for-profit integrated healthcare network serving a 17-county region comprised of northern Nevada, Lake Tahoe and northeast California. Renown is one of the region’s largest private employers with a workforce of more than 6,000. It comprises three acute care hospitals, a rehabilitation hospital, skilled nursing, the area’s most comprehensive medical group and urgent care network, and the region’s largest and only locally owned not-for-profit insurance company, Hometown Health. Renown has a long tradition of being the first in the region to successfully perform leading-edge medical procedures. For more information, visit renown.org.

Original article can be accessed here.

States are increasingly turning to community paramedicine to help fill the gap in the health care workforce. States have been experimenting with community paramedicine programs for the last five years or more. Expanding the role of licensed or certified emergency medical technicians—or EMTs—and paramedics to provide non-emergency preventive health care services directly to patients in their communities can be cost-effective and make up for health care work force shortages.

Nevada Assemblyman James Oscarson said he was motivated to sponsor a community paramedicine law in 2015 because of the number of runs made by ambulances to pick up individuals who didn’t need to go to emergency rooms or be admitted to the hospital. Oscarson is a nurse and currently works as director of community relations at his hometown hospital.

In many rural areas of Nevada, doctors and nurses are in too short supply to provide the primary care services community residents need to stay healthy. But with the help of paramedics, according to Oscarson, patients with chronic diseases and other health needs may be better able to access the services required to manage their diseases, and prevent complications and admissions to the emergency room or hospital.

“Community paramedics offer extensive background experience and will provide for better access to health care,” Oscarson said. “Nevada now has an opportunity to fill unmet or unrealized community primary care and health needs. Using EMS providers in an expanded role will increase patient access to primary and preventive care, save health care dollars and improve patient outcomes.”

Nevada Gov. Brian Sandoval signed the bill into law on May 25, 2015. The bill allowed the state to write necessary rules for implementation on Jan. 1, 2016.

In late August, Nevada received approval of a state plan amendment from the Centers for Medicare and Medicaid to provide Medicaid reimbursement for medically necessary community paramedicine. Services must be part of the care plan ordered by the patient’s primary care provider and may include evaluation and health assessments; chronic disease prevention, monitoring and education; medication compliance; and immunizations.

“With approval of Medicaid reimbursement, I see tremendous opportunities opening up for Nevada,” said Oscarson.

Starting with Minnesota in 2011, 16 states and the District of Columbia have passed laws on community paramedicine. North Dakota dipped its toes in the water in 2013 with a feasibility study and by 2015 adopted statewide rules. In 2016, the West Virginia legislature authorized six demonstration sites. North Carolina and Maine provide some state funding to support community paramedicine efforts and Minnesota also has secured Medicaid reimbursement.

Janet Haebler, senior associate director of state government affairs for the American Nurses Association, said community paramedicine “strives to fill in gaps in services that previously had been provided by public health and home care nurses but were lost with funding cuts.”

Haebler underscored the necessity of a clear definition of the community paramedic role with patients, as well as the roles of all health team members who deliver such care. For that reason, in states with new community paramedicine laws, nurses have come to the table with EMTs and others to ensure that every patient has access to high-quality care from all health care providers.

In some communities and states, community paramedicine is part of a larger reform called mobile integrated health care. Mobile integrated health care includes services such as providing telephone advice to 911 callers instead of ambulance dispatch; providing community paramedicine care, chronic disease management, preventive care or post-discharge follow-up visits; and transport or referral to an array of health care settings beyond hospital emergency departments.

“We use a nurse to triage calls that come into our 911 number,” said Matt Zavadsky, director of public affairs for MedStar Mobile Healthcare, the ambulance service for Forth Worth, Texas, and 14 nearby cities that serve nearly a million people. “If you have twisted your ankle, for instance, our nurse may suggest that you go directly to an orthopedic clinic. We can even send a taxi to transport you.”

Zavadsky said Texas’ Section 1115 Medicaid waiver provides for reimbursement of the full array of mobile integrated health care services, including community paramedicine. But the waiver doesn’t eliminate the dilemma that ambulances are paid as transportation services, not health care services, under both Medicaid and Medicare. Transportation by the ambulance to a setting other than a hospital emergency room is not reimbursable, neither is providing medical treatment without accompanying transportation service.

“It doesn’t make sense that our ambulance can arrive and provide glucose for a diabetic who has forgotten to eat and is unconscious, treat the patient effectively and arrange for a follow-up visit to the patient’s physician, but not get paid unless the ambulance takes the patient to the hospital emergency department,” said Zavadsky.

Zavadsky and other members of the EMT community are working to change federal policy to make ambulance assessment and referral a reimbursable Medicaid and Medicare service, something they hope can make a significant impact on many individuals who need more accessible care and save money for the health care system overall.

Original article by Deborah Miller, and can be accessed here.

September 1, 2016

Freestanding emergency rooms are expanding fast in North Texas. You can hardly drive down any major street in Dallas without seeing one. But are they good for patients?

Park Cities, Allen and Plano are the newest locations for these slick and efficient facilities that claim the capabilities and services of full-service emergency rooms, guaranteeing treatment without the wait of a hospital-based emergency room. In a sense, patients receive the convenience of an urgent care center, but they anticipate receiving the same quality of a hospital emergency service.

Unfortunately, urgent care is not the same as emergency care, and freestanding emergency rooms simply cannot provide the same level of emergency treatment as hospitals. Urgent care centers, or walk-in clinics, are usually open outside of regular business hours, including evenings and weekends. They are ideal for treating minor injuries, such as sprains, or illnesses like fever or sore throat. Emergency rooms — open 24/7 — are the best place for treating severe or life-threatening conditions. True ERs can handle trauma, X-rays and surgical procedures and have access to specialists.

The freestanding emergency room concept is not new. According to health care management consultant Cherilyn G. Murer, the facilities were established in the early 1970s to expand services to underserved and critical-access areas that cannot support the economic obligations of a dedicated hospital. The increased demand for emergency care has prompted the growth of these types of emergency rooms, as hospitals cut back on emergency departments.

It is expensive to sustain a full-service hospital with surgical suites and sophisticated imaging capabilities. It is even more difficult in smaller, rural communities.

In response, freestanding emergency rooms provide immediate care, with less urgent patients treated and discharged, and more complicated cases transferred immediately to affiliated hospitals with more robust facilities. It seems like a perfect solution to provide appropriate and quality care throughout the region.

Unfortunately, innovative medical entrepreneurs recognize an opportunity to label urgent care services as emergency room care and are able to charge accordingly. A typical urgent care visit may cost $50. But re-label it as an emergency room visit, and your average charge inflates to more than $300. Not a bad pricing strategy.

Freestanding emergency room advocates claim that consumers resent long waits in hospital emergency rooms and prefer a more convenient, efficient solution. While this may be true in some cases, we should also recognize that hospital-based emergency rooms are staffed with trained technicians and clinicians prepared to respond to the most critically ill. A burst appendix, full cardiac arrest or a severe stroke all require immediate surgical or diagnostic intervention.

A fully staffed surgical suite is available 24/7. The cardiac catheterization department times “door-to-needle” care, and the MRI is always available along with technicians for immediate treatment. Suffering a stroke? Clinicians are standing by to administer clot-busting medicines or initiate other protocols for emergent care. These are just a few examples of the preparation and readiness that a hospital-based emergency room provides. And consumers expect this level of care.

What they don’t realize is that a freestanding emergency room is ill-equipped to treat these types of illnesses. Instead, the patient will be diagnosed and then transferred to a hospital-based emergency room for treatment. This wastes critical time to treatment and generates additional expenses for the second emergency room care.

But perhaps even less consumer friendly are the exorbitant charges incurred by the growing number of patients at freestanding emergency rooms. The arriving patient might pay a minimal co-pay or even a no-pay; however, consumers complain about charges after they leave. They are often bombarded with uncovered charges due to insurance plan design or high-end deductibles.

Freestanding emergency rooms are an example of health care entrepreneurs responding to consumer demands with good intentions to benefit economic interests. However, in many cases, these facilities stray far from the original intent to provide care in underserved areas and may even cost patients precious time for treatment in hospitals.

Britt Berrett is director of the undergraduate program in Healthcare Management in the Naveen Jindal School of Management at UT Dallas. Email: britt.berrett@utdallas.edu

Original article can be accessed here.