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This past year, the Centers for Medicare & Medicaid Services (CMS) announced it would award up to $1 billion in Healthcare Innovation Grants to applicants with the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and the Children’s Health Insurance Program. Awards ranged from $1 million to $30 million and cover a period of up to three years through annually renewable cooperative agreements.
The objective of this initiative is to encourage creative partnerships that will identify and test new care delivery and payment models with the goal of addressing the unmet healthcare needs of underserved or low-income populations while reducing healthcare costs and hospitalizations. The caveat was that the projects had to be ready to deploy rapidly—within six months of the award.
Approximately 3,000 providers, payers, local government, public-private partnerships and multi-payer collaboratives from across the country applied. Only 107 grants were awarded.
The first of the awards were announced in May, followed by a second batch a month later. Of the organizations awarded a Healthcare Innovation Grant, three included an EMS component: Prosser (Wash.) Public Hospital District, Regional Emergency Medical Services Authority (Reno, Nev.), and Upper San Juan (Colo.) Heath Service District. All three involved a version of the community paramedic, each with a slightly different focus based on the particular needs of their individual communities.
Officials from each of the organizations say that news of the award was both exhilarating and daunting. They’re keenly aware that the eyes of the EMS industry throughout the nation are watching.
Prosser Public Hospital District (Prosser, Wash.)
Prosser Public Hospital District (PPHD) serves a large, scarcely populated area of eastern Washington State, with its own EMS system of 30 EMTs and paramedics.
PPHD EMS Manager Mike Schreiner says the secret to their successful grant application, for which they were awarded $1,470,017, was basing it on a project they had been working on for the past two years. “By the time we learned of the grant, we’d done a lot of background work,” he says. “We were very fortunate that we were already going down that road. We just needed to fine tune the money to make it work.”
The basic premise of PPHD’s Community Resource Medic program was to involve EMS, an under-utilized resource with regard to high-risk patients, in patient care to prevent a crisis. Because EMS is hospital-based, it was easier to incorporate into the solution, Schreiner says. But he also looked to outside sources for inspiration, particularly the Eagle County, Colo. community paramedic program, he says.
The Community Resource Medic program started by identifying a specific class of patients who, once released from the hospital, often fail to follow through with their primary care physicians. Frequently, these patients suffer from chronic illnesses. Without proper follow-up care, their conditions worsen and they end up back at the hospital, often by ambulance.
After some investigation, Schreiner says they learned why these patients were missing follow-up appointments. “I’m seeing the third generation of people who only know how to call an ambulance and go to the hospital for healthcare,” he says. Additionally, Prosser is home to a large Hispanic population. Although many Spanish-speaking providers serve at the farm workers clinic, cultural issues beyond language exist that also need to be addressed.
Once the program was launched, community resource paramedics visited patients at home within 48–52 hours of discharge, providing medical monitoring, basic lab work, patient education and encouragement to keep follow-up appointments. “Our goal is to drive patients back to primary care doctors,” Schreiner says.
Prior to the grant, the biggest deterrent for the program had been reimbursement. So Schreiner brought the idea of applying for the Innovation Grant to the team. “[They] really took it from there,” he says. “This is a whole new program.”
The grant funds community paramedics to continue in the role pioneered by the Community Resource Medic program, to increase access to primary and preventive care, provide wellness interventions, decrease emergency room utilization and improve outcomes.
One of the main objectives is to make a big enough difference so that hospitals, the federal government and the community at large would see the benefit and fund it. “Our goal is to prove that it can be sustainable,” he says.
Schreiner also hopes that the program will bring EMS closer into the fold of the medical community. “We want to be seen as problem solvers,” he says. He admits there was some skepticism early on from home health nurses and physicians. Again, he turned to other programs for advice. By focusing on episodic care and convincing physicians that the paramedics weren’t providing primary care, attitudes shifted. “They wondered, ‘why haven’t we done this sooner?’” he says.
Over a three-year period, Prosser Public Hospital District’s program will train an estimated 10 workers, including community paramedics, medical information coordinators, registered nurse case managers and medical doctors.
Regional Emergency Medical Services Authority (Reno, Nev.)
Founded in 1986, the nonprofit Regional Emergency Medical Services Authority (REMSA) is the sole provider of ground and air ambulance services in the Reno-Sparks area. Four hundred employees serve a population of 400,000. However, due to a large influx of tourists, that number increases dramatically depending on the time of year and events.
The project, the REMSA Community Health Early Intervention Team (CHIT), received $9,872,988 in funding through the Innovation Grant program. The estimated three-year savings is $10,500,000. According to REMSA’s grant application, the savings will come through “reductions in non-urgent emergency department visits, unreimbursed emergency department costs, hospital admissions, and hospital readmissions, as well as decreased hospital stays, fewer ambulance transports, and improved overall healthcare and continuity of care.”
The key to being awarded the grant, says REMSA CEO Patrick Smith, was establishing critical partnerships within the community, including the University of Nevada-Reno School of Community Health Sciences, the Washoe County Health District, the State of Nevada Office of EMS and local hospital systems. He explains that REMSA has a significant advantage in that these organizations have been working together since the ambulance company was created by a blue ribbon committee 25 years ago. “The key was aligning the interests,” Smith says. “By doing that … all the components share the savings and [can] be more innovative.”
The project has three components. The first is to create an alternate pathway for individuals to access care. Lower acuity calls will be triaged into a system that offers advice from a nurse over the phone.
If the call warrants, a community paramedic could be sent to the patient to assess the problem. The paramedic will receive specialized training to either treat the patient at home or determine whether to transport the patient to an urgent care facility, physician’s office, mental health facility, or via ambulance—the more traditional route—to the hospital.
The third leg is allowing paramedic ambulances to also transport lower acuity patients to alternated destinations—such as urgent care facilities, physician’s offices and mental health facilities—other than an emergency department, or treat and not transport. REMSA has requested a waiver from CMS to provide these alternate services and is awaiting approval. This is a significant change from the traditional payment approach by CMS, and could affect the entire ambulance industry. To implement, REMSA will train approximately 22 workers and create 22 new jobs, including community paramedics. “This will be a new position,” says REMSA Vice President Mike Williams. REMSA is working with teaching partners at the University of Nevada-Reno using curriculum developed by North Central EMS Institute.
Smith is mindful of those who have been paving the way. “There are a lot of pioneers out there. We say ‘thanks’ and let’s continue to learn from each other,” he says.
Upper San Juan Health Service District (San Juan, Colo.)
Upper San Juan serves a remote, rural region, of more than 3,400 residents living in medically underserved areas of southwestern Colorado. Like Prosser, it had already begun an outreach program using community paramedics to provide an interface for primary care physicians.
“We’ve already been working hard to show that we are trying to change the traditional healthcare [model] where people get sick and come in to the hospital,” says Upper San Juan Health Service District CEO Bradley A. Cochennet. “This is an outgrowth of a desire to do more than just provide defensive medicine. The problem was that none of it was being reimbursed.” Cochennet also admits he had a ringer for the grant proposal. “One of our EMTs is a grant writer,” he says.
The centerpiece of the Health Service District is the three-year old Pagosa Springs Medical Center, the only hospital within 60 miles. It’s home to Pagosa Springs EMS, a four-ambulance ALS and BLS service that provides emergency medical response to Archuleta County and portions of Hinsdale and Mineral Counties.
For the past three years, the district has been documenting areas of improvement, including early detection of heart attacks and strokes. In order to more fully serve a remote population, the hospital had already developed an advanced telemedicine program.
The $1,724,581 grant will expand the current model that focuses on patients at risk for heart attacks and strokes through cardiovascular early detection and wellness programs, remote diagnostics for cardiologist consultations and a telemedicine acute stroke care program. A portion of the grant will be used to upgrade and retrain its EMS division to manage urgent care transports and in-home follow-up patient care.
But first, they had to identify the obstacles to follow-up care and provide solutions. In southwestern Colorado, a huge hindrance was travel time and expense—a cost not normally considered in healthcare estimates since it’s often borne by the patient.
“You are looking at a quantum leap in savings,” Cochennet says. He estimates that in six months, the savings in the cost of helicopter transports, the most common form of medical transport for acute patients, is $300,000. Overall, the district says this program will reduce healthcare costs by approximately $8.1 million during the three-year grant period.
“That’s just the money. What is the price of an extra year of life or a better quality of life?” he asks.
All three organizations report that, so far, working with CMS has been remarkably smooth. “Our experience with this grant has been very positive,” Cochennet says. Each grant winner is assigned a program officer to help with the process. So far, they have submitted their operations plans and expect to get underway with their projects as soon as they get the go-ahead from CMS. “I feel confident coming out of this that, with their help, we will be very successful,” Schreiner says.
The key to launching these programs goes beyond the immediate savings. A large part of the process is to create a program that can be duplicated anywhere in the U.S. By providing grant money, CMS hopes to spur such innovative programs as the ones proposed by REMSA, Prosser and Upper San Juan. “These will be tools people will want to use,” Cochennet says.