It’s a scene that’s played out four times in the last year, two of which occurred after ambulance trips to the hospital: Peggy, an 85-year-old female, sits quietly in her hospital bed where she’s been receiving treatment for complications from chronic obstructive pulmonary disease for the last four days.
After being seen by physicians and specialists she’s now ready to be discharged. A member of the hospital’s case management staff comes to visit her and reviews several pages of discharge instructions, including her regimen of prescription medicine and expectations for follow-up visits with primary care and specialty physicians. Peggy, like other patients in her position, would typically need to rely on herself or a support system of friends and family to navigate this daunting process.
The scenario just described is the events as they played out for one Southern Arizona resident, but any number of other residents could easily relate to this experience. In spring 2013, Golder Ranch Fire District (GRFD) decided to investigate new service delivery models that would provide a superior service to our residents and have the potential to capture alternative sources of revenue independent of property values and reimbursement trends. The mobile integrated healthcare service delivery model had demonstrated promise in the areas of improved care and as an alternate source of revenue in both private and third-service EMS providers, but had yet to be widely embraced by the fire service community. Nevertheless, the decision was made to move forward with the development and implementation of what would later be named the Community Integrated Healthcare Program (CIHP).
Over the course of a year, the CIHP was developed through the involvement of personnel in every division of the GRFD, including our International Association of Fire Fighters (IAFF) Local—the North Tucson Fire Fighters Association 3832—and community stakeholders, such as Oro Valley Hospital and the Northwest Allied Physicians, as well as neighboring jurisdictions including Northwest and Avra Valley Fire Districts. The goal was to develop a regional program for the purposes of promoting a healthier community, reducing hospital re-admissions and rightsizing the care of our residents while ensuring participant access to healthcare resources are streamlined through a single point of contact. On June 30, 2014, these goals were realized and the CIHP became operational.
Case Study: Participant Access
Unlike previous hospital stays, this time Peggy is presented with an alternative to managing her post-discharge care on her own. The hospital’s case management representative explains there’s a new program the patient can opt-in to that would engage the local fire department. Through her participation in CIHP, she’ll receive one-on-one in-home care by highly trained professionals, have access to care 24 hours a day at no additional cost, and a community integrated paramedic (CIP) will visit her at home multiple times over the course of the next 30 days.
Program participants receive a minimum of six interactions—a combination of home visits and phone follow-ups—by Golder Ranch Fire District CIPs. Photo courtesy Joshua Hurguy
GRFD CIP’s are all experienced paramedics who have undergone an additional 60 hours of training in the areas of nutrition, disease-specific processes, smoking cessation, lab value interpretation and additional pharmacology. Training is delivered through a combination of class time at our local community college and in-house training provided by one of our community stakeholders, Oro Valley Hospital.
Operationally, the CIPs are deployed from two stations within the boundaries of GRFD, with one unit in service Monday through Friday from 8:00 a.m. to 5:00 p.m. and another in service 24 hours a day to supplement any surges in capacity, as well as to provide the CIP response should a participant access 9-1-1. This tiered deployment isn’t only familiar with members of the fire service, but also allowed the GRFD to implement the program using existing budgeted positions and equipment.
Participant access to the CIHP occurs at the time of discharge with the determination of eligibility. Eligible patients are those who reside within the boundaries of the Golder Ranch, Northwest, and Avra Valley Fire Districts, and are being discharged following inpatient admission for chronic obstructive pulmonary disease, congestive heart failure, diabetes, myocardial infarction or pneumonia. Hospital case management staff presents the program to eligible patients. Those who opt-in to the program sign a release of information form that’s then forwarded, along with a face sheet and discharge summary, via secure fax to one of the program’s 24-hour EMS captains. The EMS captains then create an electronic patient care report (ePCR) using the ZOLL EMS Mobile Health application and contact the participant to set up the initial appointment. All of this is typically accomplished within 24 hours of the participant’s discharge from the hospital.
Case Study: Initial Visit
One day after opting into the program, Peggy receives the first in-home visit from her GRFD CIP. During the course of the visit, she receives a physical assessment including 12-lead ECG, a home safety and environmental survey, and a baseline medical knowledge survey. Additionally, the CIP explains the discharge instructions to Peggy and her family members, offers to assist with appointment setting and keeping, and reconciles all of her medications. Peggy now has additional knowledge, tools and a support system in place to successfully navigate this most recent hospital discharge.
Expanding Role, Not Scope
The role of the GRFD CIP is to work in concert with hospitals and primary care and specialty physicians to improve the overall health of the population served. This is accomplished through the integration of scheduled home visits and phone follow-ups, coupled with 24-hour support, which works in tandem with the traditional 9-1-1 system. This allows the CIP to function both as a patient advocate and the eyes and ears of the physician at the participant’s residence.
The care provided during home visits is guided by a series of administrative orders developed with the cooperation of GRFD Medical Director Cary Keller, MD, and Prehospital Coordinator Amber Prince, RN. Each administrative order is a methodically scripted algorithm designed to support increasing the participant’s knowledge and ability to self-manage their particular disease process. They’re also designed to transition seamlessly into our EMS administrative orders should the participant begin to decline, access 9-1-1 for an exacerbation of their condition or experience an acute medical emergency. This process allows our CIP’s to accurately gauge the participant’s progress during their time in the program and identify new onset conditions.
Case Study: Right-Sizing Care
Three days after returning home, Peggy begins to feel her heart racing in her chest—a feeling she’s not previously experienced. This event coincides with the second home visit by her CIP. Upon examination, 3- and 12-lead ECGs show a new onset of atrial fibrillation, with 2–5 beat runs of non-perfusing v tach. Peggy isn’t experiencing chest pain or other cardiac symptoms and is already scheduled to see a cardiologist in eight days. The CIP works with the cardiologist to move her appointment four days earlier and schedules a follow-up visit for the next day.
Before the CIP arrives for the follow-up, Peggy begins to experience dizziness and lightheadedness coinciding with the racing in her chest. Recognizing these as symptoms Peggy’s CIP told them to be aware of, her family takes her in for evaluation at a local ED. The CIP meets Peggy and her family at the hospital and provides recent patient data to the ED staff. After a short observation period, Peggy is discharged from the ED without an inpatient admission.
By educating Peggy and her family with the signs and symptoms to be aware of, having historical data ready to share with ED staff, and coordinating with her cardiologist, an ambulance transport and possible inpatient admission to the hospital were avoided.
During the course of the 30 days participants are in the program, they receive a minimum of six interactions—a combination of home visits and phone follow-ups. The level and number of patient interactions are tailored to meet the acuity needs of the individual participant, while providing the foundation for reliable data gathering relative to the effectiveness of the program and cost to provide the service. Program effectiveness is measured using participant health knowledge and satisfaction surveys. The cost to operate the program is measured in terms of employee-related expenses, as well as durable and disposable supply costs.
The surveys used to measure program effectiveness are delivered in three parts. The first part consists of a health knowledge survey. The participants are asked to gauge their knowledge of their disease process, ability to self-manage, and prospects for a healthy future. Additionally, this survey establishes baseline information on access to a primary care physician, number of recent hospital stays and doctor’s office visits, and number of 9-1-1 accesses.
The second part of the survey process is to administer the survey again on the final visit of the 30 day program. The baseline and final scores are compared to determine how well the program met the individual participant’s needs, as well as the participant’s progress toward the stated goals of the program.
The level & number of patient interactions are tailored to meet the acuity needs of the individual participant, while providing the foundation for reliable data gathering relative to the effectiveness of the program & cost to provide the service.
The final part of the survey process is a customer satisfaction survey that seeks to gauge how the participant felt about the program overall. Survey data is analyzed on a quarterly basis to identify areas where the program is effective, needs improvement and has an opportunity for expansion.
Along with employee-related expenses and supply usage, the cost to operate the CIHP is also compared to potential savings to the healthcare system, as well as potential loss to the organization through repeated ambulance transports.
The reimbursement base rate for all ambulance providers in Arizona is determined by the Arizona Department of Health Services Bureau of EMS (AZDHS BEMS). The average patient charge for the GRFD is approximately $1,200 per transport. Over the last fiscal year, the GRFD has seen a decline in its reimbursement rate from insurers and is currently holding steady at 47%, resulting in a cost recovery of $564 per transport. Statutorily, the GRFD is required to balance bill the patient for the remaining cost of the transport, which isn’t always successful. Additionally, residents of the GRFD have the ability to purchase a yearly EMS transport subscription for $76 per year and limits collections to third party billing.
Case Study: The Final Visit
After 30 days and eight home visits, Peggy is ready to graduate from the program. The CIP arrives for her last appointment and completes all steps of the algorithm, including administration of the final and satisfaction surveys. She’s presented with a certificate of completion bearing her name along with the signatures of her CIP, the EMS chief and the fire chief. Peggy and her family express gratitude for the service as well as a desire for the visits to continue; however, they understand how to better manage Peggy’s disease process and how to seek the appropriate level of care, including 9-1-1, should problems arise.
Proof of Concept
In analyzing the data gleaned from the surveys relative to this participant, we were able to see the areas of the program where we were achieving our goals and areas where we needed to show improvement. The survey was developed by Chief Les Caid with the Rio Rico Fire Department in Santa Cruz County, Ariz.
In the interest of developing consistent data to prove this concept with the goal of attaining sustainability, the GRFD CIHP uses the same survey. The initial and final survey consists of 18 questions delivered in 44 total parts, using a combination of Likert scales, yes or no, and true or false questions.
The first 14 questions, along with the 18th, and their associated parts, speak to the first goal of the CIHP: promoting a healthier community. Working toward the goal of promoting a healthier community, Peggy showed positive changes—at times as high as two points—in nine of the survey metrics, negative deflections in 11 of the metrics, with no changes between initial and final surveys in the remaining 20.
With regard to our second goal, reducing hospital readmissions, computer aided dispatch records along with ePCR data is reviewed and confirmed with hospital information. With Peggy there were no 9-1-1 accesses or EMS transports, and there was one observation admission to the ED as discussed earlier.
In regards to the final goal of right-sizing the care for the community, the remaining three survey questions and their associated parts provide this insight. In these areas our participant showed increases in the number of office visits, which correlated with a leveling of ED visits and a decrease in 9-1-1 access.
When the survey data is viewed as a whole for all participants who complete both the baseline and final surveys, positive gains are noted in 26 of the metrics used to measure the goal of promoting a healthier community, with the remaining 13 showing a negative deflection. The areas of negative deflection relate to the questions concerning overall health affecting everyday activities, general feeling of emotional stability, and overall heath outlook. These areas of negative deflection indicate the areas to focus on for program improvement moving forward.
In terms of the cost to provide the service, GRFD current reimbursement trends demonstrate an average deficit of $636 per transport, which is either passed along to the patient or subsidized through participation in the GRFD EMS membership program. In examining the budgetary impact to the organization relative to personnel, vehicle and supply costs, the cost per participant is less than our average write-off amount. As such, the CIHP saves money not only for the healthcare system and the participant, but the organization as well.
As a fire-based EMS provider, we face several challenges moving forward. The goal is to create a sustainable program that leads to an alternate source of revenue independent of tax levies and reimbursement trends. It was difficult to secure funding sources from healthcare facilities and insurers at the outset; however, we have now almost overcome this obstacle.
Retaining our providers is another challenge. Those who volunteered to pilot this program and proof the concept in the region are all talented providers and motivated personnel who have already begun to promote to leadership positions within our organization. As such, various opportunities to incentivize the position are being examined with the support of our IAFF Local.
Despite these challenges, it’s evident from the data gathered and the feedback from the participants that the CIHP is an asset to the organization and the community we serve.