Administration and Leadership, Mobile Integrated Healthcare

East Baton Rouge Parish EMS Helps Patients Navigate Healthcare System

Issue 7 and Volume 40.

East Baton Rouge Parish (EBRP), which encompasses Baton Rouge, La., is experiencing a medical crisis. Due to obstacles in the community or gaps in coverage, a small but significant segment of our population receives inadequate medical care. As a result, these individuals often turn to EMS, which offers around-the-clock, easily accessible care.

The ED, however, isn’t the proper venue for many of these individuals. EDs are designed to deal with acute, life-threatening issues. The misuse of emergency services leads to misappropriated medical resources, causing those who actually need emergent care to suffer as well as those seeking care for non-emergent issues. A vicious cycle then precipitates as these patients will only receive temporary relief of their symptoms. When the problem returns, they again call 9-1-1 for transportation. The underlying cause of their symptoms is still not addressed—it’s simply bandaged.

In an effort to eliminate obstacles and close the gaps in medical services, EBRP EMS launched a community integrated health program (CIHP) modeled after several other successful programs across the United States. Their CIHP is designed to identify individuals called the “high utilizer group,” many of which have chronic medical and/or mental health conditions and are inadvertently abusing the emergency system, and educate them about how and when to use available primary care resources.

Redirection from emergency services to more appropriate levels of care is the key focus, but preventing unnecessary readmissions for patients with stable, chronic conditions such as congestive heart failure is also a top priority.

STAKEHOLDER COLLABORATION

The success of the CIHP is partly due to the collaborative efforts of various stakeholders within the parish. Using an integrative, holistic approach, enrollees are provided with a biopsychological model of care that promotes overall wellness and disease prevention.

Connecting patients with social and community support services, in addition to addressing medical needs, is integral. One partnership is with the Baton Rouge General Medical Center’s Family Medicine Residency Program (FMRP). Because high utilizers often seek care for conditions best managed in outpatient settings, the primary care services provided by the residents are a huge asset to the CIHP.

During the CIHP rotation, resident physicians develop competencies fundamental to family medicine, such as patient-centered medical care, practice-based learning and improvement, and systems-based practice.

Working with CIHP provides valuable experience for resident physicians and provides quality health services to those most in need. FMRP also provides access to the behavioral science department.

Many high utilizers have mental health or substance abuse disorders and are in need of related social services. Faculty and interns from the Louisiana State University (LSU) Graduate School of Social Work provide invaluable guidance and share knowledge of resources available within the community. The social work interns play a vital role in connecting patients with social and community support systems to empower high utilizers to be invested in their own healthcare. This assistance allows community paramedics to educate enrollees about their medical conditions and how to access local resources.

Another collaboration exists with industrial engineering students from LSU, who are instrumental to data analysis. They play a significant role in maintaining and improving the telemedicine component that allows for direct patient-physician dialogue in the field. Through these collaborations, we’re unified in addressing education and prevention as mechanisms to positively ameliorate the health of our community.

HOW THE CIHP HELPS

An inaugural enrollee to the CIHP was an elderly female, living in a dilapidated mobile home 25 miles northeast of the city, diagnosed with end-stage cirrhosis of the liver and metastatic cancer. Her prognosis grim, she was sent back to her paltry dwellings to die alone without end-of-life care.

As a result of her disease process, her abdomen would quickly fill with ascitic fluid, which demanded continuous drainage. Without transportation, she was unable to attend scheduled infusion clinic appointments to have therapeutic paracentesis performed to remove excessive fluid from her abdomen.

Uninformed of her options and the resources available to her, she sat in her home nauseous and in significant pain, unaware that Medicaid benefits would allow her to be transported to her appointments for free.

Though supplied a prepaid cellphone by the state, our patient couldn’t afford to purchase more than 20 minutes of service a month. The bureaucracies associated with the medical system in this country leave few tasks to be accomplished in such a short time.

Therefore, she was forced to continually pursue her only perceivable viable option: dialing 9-1-1. This resulted in transportation to an ED, where she found temporary relief of her symptoms through paracentesis. Helpless and desolate, she called 9-1-1 every 10–12 days for reprieve.

The CIHP eventually stepped in to assist this terminally ill patient by arranging transport to infusion clinic procedures and other medical appointments. Reluctant to give up her independence, she vehemently refused to move into a nursing facility for a higher level of care. While the CIHP worked to provide her with palliative measures and hospice care, seemingly insurmountable obstacles routinely presented.

At some point, navigating the healthcare system became surreal for both the patient and the CIHP. Admission to hospice would require placement of a semi-permanent internal drain to minimize the need for outpatient paracentesis. Two community paramedics, an immediate supervisor, a family medicine resident physician and the medical director of EBRP EMS spent countless hours trying to make this a reality. Social work stepped in to explore the patient’s health insurance benefits. They discovered that few surgeons could insert a drain and even fewer accepted Medicaid. Furthermore, the patient lacked a designated primary care provider, which made it difficult to obtain a referral for the operation.

Through diligence and perseverance, the CIHP found a provider to perform the operation and was able to accompany the patient on subsequent appointments to ensure she was being informed and educated about the diagnoses, prognoses and procedures she was facing. Rather than living the remainder of her life in turmoil and agony, the CIHP helped her pass away peacefully.

REDUCING OVERUTILIZATION RATES

The barriers faced by our indigent population, combined with limited resources, result in overutilization of emergency services for psychiatric issues and exacerbations of chronic conditions, such as congestive heart failure or obstructive pulmonary disease, at the expense of the taxpayer. This compromises the quality and accessibility of healthcare for all parishioners.

Between January and July of 2014, 1,999 patients were identified as the high utilizer group. These patients, representing 0.5% of the total parish population, called 9-1-1 a combined 7,168 times, often for non-emergent issues. This comprised 27% of the EMS call volume during that time period and resulted in a staggering 5,514 (29%) total transports to an ED. EMS and local EDs, however, lost significant revenue on a great majority of these calls totaling non-recoverable losses of over $8.65 million within six months.

Since its inception, the CIHP has been incredibly successful in reducing overutilization rates of EBRP emergency services. With its multidisciplinary, community approach, significant decreases in both 9-1-1 calls (p <0.01, t = -13.07, df = 8) and the number of ambulance transports (p <0.01, t = -11.95, df = 8) has been demonstrated in just five months of operation.

Enrolled patients made on average 27.33 calls to 9-1-1 per month prior to the intervention with 23.17 of these calls resulting in ambulance transportation to an ED. An average of 57 minutes and 28 seconds was spent by EMS per each of these calls. Of the 4.17 calls that were released, an average of 24 minutes and 41 seconds was taken clearing the call.

A telemedicine component allows for direct, patient-physician dialogue in the field, providing valuable experience for resident physicians and providing quality health services to those most in need.

 

A telemedicine component allows for direct, patient-physician dialogue in the field, providing valuable experience for resident physicians and providing quality health services to those most in need.

Because the number of 9-1-1 calls per month by enrollees was substantially reduced to 11 with only two resulting in transportation after implementation, a time savings of 22 hours, 15 minutes, and 50 seconds per month was realized by EBRP EMS. Pre-intervention unreimbursed costs to EMS also plummeted from $36,066 to $2,199 per month. These tremendous accomplishments are associated with CIHP enrollment (p <0.005, X2 = 35.75, df = 1).

ROOM FOR IMPROVEMENT

Investing time, effort and money has proved immensely beneficial. It has led to a drastic reduction in non-emergent calls to EMS and sizeable fiscal savings, allowing for more efficient allocation of limited resources.

As the CIHP grows and establishes its roots within EBRP, the hope is to increase enrollment in the CIHP and expand to address different areas of our indigent community’s needs. Nevertheless, obstacles persist. A substantial area of concern is the lack of communication within our local medical network.

Improving patient care mandates amelioration of the electronic exchange of information rapidly and without error. This would facilitate diagnosis and treatment as well as avoid duplication of efforts across disciplines. Building a central hub of patient information and providing immediate, electronic access to the healthcare delivery organizations in our municipality will ultimately result in better care by increasing efficiency and effectiveness of the system itself.

ImageTrend, a company that understands the importance of a cohesive health information network, diligently aims to achieve this goal for us. EBRP EMS, along with several other entities in the state, uses ImageTrend electronic patient care reporting (ePCR) programs to standardize report writing.

By purchasing the report writing program, the state of Louisiana has paved the way for an easier transition to future ePCR programs from ImageTrend, granting unparalleled statewide access to this health information system.

CONCLUSION

EBRP has been hit particularly hard by disparities in healthcare, which are becoming increasingly more evident in the U.S. In less than three years, the parish has lost two major urban emergency facilities that provided almost 40% of all emergency care. While we can’t immediately change the inefficiencies of our healthcare system, the CIHP proves that we can work together to provide a more cohesive, accessible delivery modality that empowers and educates the community to make appropriate, informed decisions about their own health.