In today’s rapidly changing healthcare environment, many EMS organizations (and EDs) find themselves squeezed between mandates to provide services and reimbursement rules that only provide payment for “medically necessary” services. Often, 9-1-1 calls for service come from individuals whose conditions don’t require emergency care, but nonetheless must be transported by EMS to the ED. The losses from these non-reimbursable transports are a significant threat to EMS financial viability, create unnecessary stress on EMS staff, and divert resources away from legitimate medical and trauma emergencies.
One approach to address this problem has been to explore ways to reduce the number of medically unnecessary or inappropriate calls and to collaborate with transit and healthcare providers to provide access to more appropriate non-emergency services.
The potential for a more integrated role for EMS was outlined in “Innovation Opportunities in EMS,” a 2013 white paper drafted by the Departments of Health and Human Services and Transportation.1 A major component of the model proposed in this paper was to develop systems to divert low-acuity patients away from EDs and into patient-centered medical homes. EMS is often the first point of contact between individuals and the healthcare system, and as such, EMS is well-positioned to intervene in a meaningful way that can improve the delivery of health services while reducing overall downstream costs.
Several EMS agencies in urban areas have developed sophisticated integrated systems of EMS triage and service coordination.2 However, many EMS operations lack the administrative staff and/or financial resources to explore innovative models of integrated care. The design and effectiveness of such programs for EMS organizations of different sizes and organizational structures hasn’t yet been well documented. Preliminary results from a pilot project in Illinois, however, suggest one model of integrated care that may be promising for many EMS agencies.
ILLINOIS’ PILOT PROJECT
Following a comprehensive assessment of medical transportation needs in the southernmost counties of Illinois, the Illinois Department of Transportation (IDOT) and the Center for Rural Health and Social Service Development (CRHSSD) at Southern Illinois University’s School of Medicine established the Rural Medical Transportation Network (recently renamed the Illinois Medical Transportation Innovation Project [IMTIP]). The purpose of this new collaboration was to improve both emergency and non-emergency medical transportation in order to provide reliable, affordable medical transportation using a “one system” perspective. IMTIP adopted a triad model of integrated care that included representatives from EMS, public transit and healthcare organizations. (See Figure 1.)
Regional priorities were identified through a series of focus groups, interviews and mail surveys. One major concern identified by project members was the negative impact that medically unnecessary calls for service were having on EMS agencies.
To address this concern, the IMTIP partners chose the patient navigator model, a proactive strategy that could capitalize on the collaboration of project partners. Patient navigators (PNs)— whose role includes some degree of case management, patient education, social work and advocacy—had been used with considerable success in many areas of healthcare, and had already been adopted by several EMS agencies in a few metropolitan areas.3 It was hoped that by integrating PNs into EMS, 9-1-1 callers who were inappropriately using ambulance services and EDs could be instructed on how to access care from non-emergency transportation and healthcare providers, and social service agencies.
In order to test drive the application of the navigator model, the IMTIP proposed a three-year EMS patient navigator pilot program to introduce patient navigators at three downstate EMS organizations.
PROGRAM DESIGN & START-UP
The three EMS agencies selected to conduct the EMS PN trials varied in their size, ownership type and organizational structure. Significant differences also existed in the population size, socioeconomic status and degree of rurality of their service areas. Start-up dates for the pilots were staggered by one year so that lessons learned from the first adopters would be available to those who followed.
Each site developed a set of criteria used to refer clients to the PNs. Referrals are made by the paramedics who are sent to treat and transport 9-1-1 callers. Once a client is referred, PNs contact them to offer assistance in obtaining access to appropriate health service providers, non-emergency medical transportation services, and/or other community resources that will help them avoid future non-emergency 9-1-1 calls. PNs also educate clients on the appropriate reasons for calling 9-1-1 and the services that are available from public agencies and not-for-profit organizations. The participating EMS agencies have considerable flexibility in the specific application of the PN model so that there’s an opportunity to learn from innovations at individual sites.
The most important task in initiating pilot site operations was for each agency and PN to establish relationships with the medical, social service and public transit providers in their region. Meetings were held with public transit officials, hospitals, clinics, primary care physicians, social welfare agencies, mental health providers and others to alert these organizations the PNs would be referring new clients to their organizations as part of the PN pilot.
All three pilot sites chose RNs to serve in the PN position. These RNs were assigned to the PN position half-time during the pilot period and continued to perform other duties within their agencies. Although their medical expertise and knowledge of community services were necessary for the performance of their PN duties, they also required several important personal characteristics. In order to be successful in negotiating difficult patient needs and diverse agency services, the PNs would need to be outgoing, calm and persistent.
Very little equipment was required to launch the PNs at each site. Each navigator was equipped with a tablet computer that was used to take referrals and to track interactions with clients. PNs used Microsoft Excel worksheets designed by CRHSSD staff to record interactions with clients and to calculate estimated savings from the PN program. The PNs also had business cards they could distribute to clients listing a cellphone number clients could use to contact them whenever they had questions or needed non-emergency assistance.
Although a complete assessment of the pilot project won’t be available until the pilot period has been completed, some promising findings are evident from a preliminary review of the information reported from the first two pilot sites.
General/recurring pain and falls were among the most frequent reasons for individuals to be referred to PNs at both agencies. Other types of problems resulting in referrals included poor living conditions, clients who were unable to care for themselves, substance abuse and mental health issues. Both agencies had nearly identical percentages (14%) of referrals that were due to clients lacking transportation for their healthcare needs (e.g., trips to doctor’s office or pharmacy). Not surprisingly, many of the clients had multiple contributing conditions and circumstances that resulted in their referrals to PNs.
The project was designed to target EMS “super-utilizers,” and did in fact intervene with the most frequent 9-1-1 callers. However, the program also identified many other clients who were in need of intervention from medical providers and social service agencies; it seems clear that having PN “eyes on the ground” proves valuable in identifying individuals and providing services to many who would have otherwise fallen through the cracks of the healthcare system, possibly resulting in emergency situations at a later date.
PN interventions were broadly classified as either “educational-based” or “referral-based.” More than half of all PN interventions at both sites were educational-based, often little more than teaching clients about the role of EMS in the healthcare system and the appropriate use of EMS. Indeed, almost 90% of clients at the smaller site and 40% at the larger site required only a single intervention from the PN before reducing the number of times clients made medically unnecessary 9-1-1 calls. Even this minimal amount of targeted effort to improve health literacy helped to significantly reduce the number of unnecessary 9-1-1 calls and to redirect these clients to more appropriate treatment and transportation services.
One of the primary motivations for pilot program implementation was to determine whether EMS agencies could improve their financial standing through the use of PNs. A simple assessment of the effectiveness of the program was performed by comparing the number of medically unnecessary EMS trips required by clients who were referred to the PNs six months before and six months after their first contact with the PNs. Preliminary findings determined that the number of calls from clients who had been referred was reduced by more than half at both agencies. (See Table 1.)
To place an estimate of the dollar value of the program, the reduction in the number of 9-1-1 calls was multiplied by the average cost of each agency to respond to a 9-1-1 call. Based on preliminary estimates, the cost savings from the reduced number of 9-1-1 calls exceeded $100,000 at both agencies. (See Table 2.)
The economic value of other benefits, such as avoiding the cost of unnecessary ED visits, not having to maintain additional EMS crews to service unnecessary calls, or increased revenues to public transportation providers was not estimated in the preliminary analysis. As the program matures and more providers/ collaborators become engaged in the project, other cost savings and improvements in client welfare may emerge. Both participating EMS agencies plan to continue their PN operations after the pilot program has been completed.
Proactive PN programs may also provide EMS agencies with a head start in the type of collaborative relationships that are likely to dominate the future of healthcare. PNs at these two pilot agencies are forging relationships with primary care providers, hospitals, federally qualified health centers, public transportation agencies, home health providers, dental clinics, social service agencies and nursing care facilities. Formal agreements and protocols have been established with some of the providers, and resource lists of all referral collaborators have been developed.
The performance of the pilot program will continue to be monitored by the IMTIP staff and a research report documenting the complete evaluation will be prepared and released once the pilot period has concluded and all of the data has been analyzed.
Preliminary reports from the PNs in the pilot study have also revealed some of the challenges to working in a mobile integrated healthcare delivery environment.
PNs must learn to quickly identify patient needs and be able to match these to the types of services available in the community. However, many communities may not have service organizations able to provide the type or quantity of services needed. For example, appropriate outpatient or inpatient mental health services may not be available, or primary care practices may have long waiting lists, especially in smaller communities or rural areas.
Integrated care requires a minimum level of local services as well as a high level of cooperation from all service providers. In many areas these services may not yet be available, and providers may just be beginning to develop the level of collaboration that will be needed to serve clients in a fully integrated healthcare environment.
The lack of health literacy among large segments of the population also remains a significant challenge. Far too many individuals lack any understanding of the dire implications of inappropriate EMS use. They prefer the quick solution of EMS transport and ED treatment to riding on public transit, making appointments with primary care physicians, or sitting in line waiting for services at outpatient urgent-care facilities. The message of the “9-1-1 quick fix” is inadvertently promoted through TV and news stories, and some ED billboards even advertise short wait times. It will require a substantial health education effort to reverse these attitudes, and educate frequent 9-1-1 users to the true costs of inappropriate EMS use.
Evidence from these pilot projects—as well as the documented success of similar programs— suggests EMS agencies don’t need to wait for national-level policy changes to adapt the way they provide services and improve their financial bottom line. PN programs can provide an opportunity to avoid financial losses from non-reimbursable 9-1-1 calls while improving patient welfare.
By leveraging collaboration of service providers in their communities, EMS agencies can alter traditional “siloed” models of healthcare and capture “opportunities for enhanced access, improved diagnosis, patient follow-up and compliance, and enhanced quality of care and patient satisfaction.”4
1. U.S. Departments of Health and Human Services and Transportation. Innovation opportunities in EMS [white paper]. National Highway Traffic Safety Administration. Retrieved Nov. 23, 2015, from www.ems.gov/innovation.htm.
2. Kincaid C. (March 27, 2013.) Navigating Patients Through Healthcare: Transitioning from static to mobile healthcare agencies. JEMS. Retrieved Nov. 23, 2015, from www.jems.com/article/administration-and-leadership/navigating-patients-through-healthcare.
3. Fischer SM, Sauaia A, Kutner JS. Patient navigation: A culturally competent strategy to address disparities in palliative care. J Palliat Med. 2007;10(5):1023–1028.
4. Institute of Medicine. (June 13, 2006.) Future of emergency care: EMS at the crossroads. Retrieved Nov. 23, 2015, from www.iom.edu/Reports/2006/Emergency-Medical-Services-At-the-Crossroads.aspx.