Healthcare finance reform is dramatically changing the landscape of healthcare delivery. Economic models focusing on the goals of Institute for Healthcare Improvement’s Triple Aim are incentivizing providers to integrate their care across the continuum. A main tenet of the healthcare system’s transformation is the encouragement of the use of multidisciplinary care teams to help patients navigate our very complex healthcare system.
One of the most important collaborators in developing and implementing an EMS-based MIH-CP program is home health, including hospice. Often, when home health agencies first learn of MIH-CP programs, one of their common reactions is, “This sounds a lot like home health.” But it’s different, and here’s why.
A typical goal of EMS-based MIHCP programs is to navigate patients through the healthcare system, not to replace healthcare system resources already available in the community. Home health, including hospice, is a very valuable link in the chain of healthcare—and for qualifying patients, a logical care delivery model.
There are, however, gaps in the delivery system that home health services may not be able to fill that EMS MIH-CP programs can assist with:
- Some patients don’t qualify for home health because they don’t have the benefit available, aren’t homebound, or have exhausted the benefit period.
- It sometimes takes a day or two between the home health referral and the first visit.
- Home health patients sometimes call 9-1-1, without the knowledge of the home health agency.
Patients who may not qualify for home health may still need assistance with understanding how to manage their healthcare needs, connecting with patient-centered medical homes or resolving a number of issues that often result in preventable admissions or trips to the ED. There are also patients who aren’t aware they qualify for home healthcare or hospice and MIH-CP programs help identify them earlier and engage them with their home health partners. In fact, the National Association of EMTs recently released a survey of 103 EMS agencies operating an MIH-CP program, which revealed that 66% of operating programs responding to the survey refer patients to home health.1
Consider the following real-life scenario of a patient enrolled in the MIH-CP programs provided by MedStar Mobile Healthcare in Fort Worth, Texas.
A 73-year-old patient with chronic obstructive pulmonary disease enrolled in Klarus Home Care calls 9-1-1 for a dyspnea presentation. The traditional EMS response to this call would nearly always result in a transport to the ED, often without Klarus even being aware of the call. Instead, because this patient is registered with the Klarus/MedStar partnership, the 9-1-1 call generates an added resource to the call: a MedStar Mobile Healthcare paramedic (MHP) with specialty training provided by Klarus and access to the patient’s home health records. The Klarus staff is notified by the communications center that MedStar is responding and the on-call nurse looks up the patient’s record while awaiting a consultation call from the MedStar MHP on scene.
Once on scene, the MHP consults with the Klarus nurse and they jointly determine the appropriate clinical interventions to be implemented using protocols agreed to between the Klarus medical director and the MedStar medical director. This results in the patient receiving the necessary immediate care at the home, with a Klarus nurse following up with a home visit scheduled later the same day or the next day.
Without an EMS-based MIH-CP and home health partnership, Klarus wouldn’t know about the response until a nurse arrives for a scheduled appointment and discovers no answer at the door because the patient is in the hospital.
In addition to sharing information and resources to avoid unnecessary ED admissions, there are other synergistic partnerships that can benefit the patient and home health.
Backup services: Occasionally, the need for episodic services for a home health patient may exceed the capacity for the home health agency to respond to the patient’s need. In the past, it might be recommended by the home health agency that the patient go to the ED, or call 9-1-1 based on the patient’s symptoms. In an MIH-CP/home health partnership, the home health agency could call the EMS-based MIH-CP provider to complete the home visit for them. Onscene care coordination could occur as in the previous scenario.
Business development: Since one of the new goals of hospitals is to reduce readmissions, home health agencies may suffer if hospitals stop referring patients to them because their patients frequently return to the ED or are readmitted to the hospital. Further, home health agencies are about to be financially rewarded or penalized for readmissions in much the same way the hospitals are being held accountable. It’s therefore in the best interest of the home health agency to effectively reduce preventable ED visits or readmissions.
MedStar’s partnership with Klarus has been in place in Fort Worth for over a year, with 541 home health patients currently enrolled in the program.
The goal of a hospice agency is to help the homebound patient transition to their afterlife with comfort and compassion. The family is instructed in the proper way to access the hospice nurse if the patient begins to struggle at home. Unfortunately, when experiencing the stress and immediate concern of seeing their loved one struggle, many families call 9-1-1. That starts a domino effect: The EMTs and paramedics assess the patient and find them in clinical distress. The family is scared and often cannot locate the DNR. In those cases, most EMS providers do what they’re trained to do—start treatment and take the patient to the ED. Once in the ED, the hospital initiates care and the family may decide this is all too overwhelming and voluntarily disenroll the patient from hospice. Or, due to the high cost of the hospital admission, the hospice agency may revoke the patient’s hospice status. This scenario isn’t in the best interests of the patient or the hospice agency. The patient’s wishes aren’t fulfilled; the hospice agency is left with an ambulance bill and ED bill to pay and loses the per diem fees normally available had the patient stayed on with their service.
Now, imagine a different outcome from the same scenario: The family calls 9-1-1, the intake computer system notifies the call taker this patient is enrolled in the partnership between a hospice and EMS-based MIH-CP program. This starts an alternative domino effect: A hospice-trained MHP joins the ambulance response team and the patient’s hospice nurse is notified. When the MHP arrives on scene, they assess the patient and determine if the clinical issue is part of the hospice plan of care. They access the medications in the patient’s hospice “comfort pack,” alleviating the patient’s suffering. They then remind the family of the goal of hospice care and the wishes of the patient, and let the family know the hospice nurse is on their way. The MHP offers to wait with the family until the hospice nurse arrives and releases the ambulance back into service. As a result of the MIH-CP/hospice partnership, no transport was initiated, there was no revocation of hospice care and the patient’s wishes are realized.
This exact program has been in place in Fort Worth for over a year. A total of 179 patients at high risk for revocation have been enrolled and only 20 have voluntarily disenrolled.
Home health and hospice agencies serve a vital role in healthcare delivery. EMSbased MIH-CP services should be diligent in seeking out partnerships with them to find opportunities to add value and enhance—not replace—these services in the community.
1. Goodwin J, editor. (2015.) Mobile integrated healthcare and community paramedicine (MIHCP): Insights on the development and characteristics of these innovative healthcare initiatives based on national survey data. NAEMT. Retrieved July 14, 2015, from www.naemt.org/docs/default-source/MIH-CP/naemt-mih-cp-report.pdf.