Two of the most prevalent terms used in healthcare today are “outcome” and “value.” The growth of mobile integrated healthcare and community paramedicine (MIH-CP) programs across the country have allowed EMS agencies to bring value and improve outcomes for patients and other healthcare system stakeholders in ways beyond our traditional roles in emergency response and medical transportation.
One of the many ways to help make the case for payment policy changes to support the financial sustainability of MIH-CP programs is to demonstrate that EMS-based MIH-CP service delivery models are safe, clinically appropriate and generate a return on investment for our healthcare system partners. In other words, that they provide value.
To document the success of the various MIH-CP pilots and programs across the country, outcomes for each of them should be measured in a uniform manner across many diverse programs. Further, we need to show that an MIH-CP intervention provided by an EMS agency is a formal service delivery strategy that has a structure designed for quality outcomes and sound business practices.
After more than two years in development, the MIH Outcome Measures Toolkit was released to the EMS and healthcare community in November 2016. The toolkit contains the overview, strategy, definitions, measures, descriptions, values for calculation and the calculation formulas for leading MIH-CP service models. It’s available as a PDF or Microsoft Excel worksheet which automatically and uniformly calculates a program’s results once their data are entered. (A special ‘thank you’ to Anne Jensen from the San Diego Fire-Rescue Department for creating the automated Excel worksheet.)
Agencies operating a 9-1-1 Nurse Triage program should work with local stakeholders to
determine which outcome measures they perceive as valuable to track and report.
Photo courtesy MedStar Mobile Healthcare
Diverse Program Models
MIH-CP programs vary greatly depending on the needs of the local community, with interventions often identified after a local gap analysis. They typically have at least one or more of the following different service models: community paramedicine, 9-1-1 nurse triage, nurse health line, alternative destination transports, transitional response vehicles staffed with a paramedic and nurse practitioner or other advanced practice provider, station-based clinics, or house call physicians. Each one of these models could-and should-have their own outcome measures.
Given the preponderance of interventions being conducted in communities across the country, the measures development team decided to first focus on developing outcome measures for the community paramedic and 9-1-1 nurse triage MIH-CP models.
Members of the measures development team have met extensively with external stakeholders and have presented at national EMS and healthcare conferences on MIH-CP programs. During these meetings and presentations, several recurring questions were often heard:
>> Do these programs generate savings by reducing the total cost of care?
>> Are these programs safe for the patients?
>> Are these programs providing quality services, as defined by external stakeholders?
>> What has been the impact on the rest of the healthcare system providers, such as primary care, specialty care and behavioral health as a result of these programs?
>> Are patients satisfied with the programs?
>> Are field personnel-those actually conducting the MIH serviceslike the program?
To address these questions, the team developed and reviewed dozens of individual metrics that were subsequently categorized into five outcome domains:
1. Quality of care and patient safety;
2. Experience of care;
4. Cost of care/expenditure savings; and
Using the Toolkit
The MIH Measures Toolkit contains 44 measures for the community paramedic service model and 43 measures for the 9-1-1 Nurse Triage model. Not every agency could or should collect and report all measures. Rather, the agency should work with local stakeholders to determine which of the measures they perceive as valuable to track and report.
Here are a few examples: local hospitals that are funding a readmission prevention program will likely find value in knowing the number and percent of readmissions avoided in the enrolled population, as well as patient satisfaction with the program. A commercial payer funding a 9-1-1 nurse triage program would be very interested in knowing if they’re experiencing a return on investment by observing how many of their insured members who call 9-1-1 are safely navigated to a clinically appropriate, alternative disposition instead of an ED.
EMS agencies looking to find economic sustainability for their MIH-CP interventions should review the data elements in the toolkit, determine their ability to track and report each of the measures, then offer those outcome measures to the payers for consideration.
Diverse funding partners may desire different measures to demonstrate their unique value propositions. Although it’s not necessary to report over 40 individual measures, we recommend that MIH-CP programs select and report at least a few measures from each of the five outcome domains Most MIH programs should report reductions in the total cost of care due to avoided hospitals admissions and readmissions, and avoided ED visits and ambulance transports.
Knowing the program’s impact on the total cost of care will assist in calculating the program’s return on investment, an essential measure for developing sustainable funding for your program.
The MIH Outcome Measures Toolkit also includes program structure measures to demonstrate that the MIH-CP program has a solid governance foundation and is committed to preventing waste, fraud and abuse. These characteristics are important because the ambulance industry has been identified as one of the fastest growing Part B Medicare expenditures and the growth in this spending is inconsistent with the national rate of growth in the number of Medicare beneficiaries.
The ambulance industry has also been criticized for fraudulent billing, primarily for non-emergency, repetitive patients. Therefore, the MIH Measures Toolkit incorporates measures that demonstrate to payers and partners that the MIH-CP program is built upon a strong foundation, the implementation was collaborative in nature and it’s designed to fill gaps in the local healthcare system.
There were two excellent consensus documents the measures team used to help with the program structure measures: the September 2012 white paper “Mobile Integrated Healthcare Practice: A healthcare delivery strategy to improve access, outcomes, and value,” as well as the MIH Vision Statement jointly developed by NAEMT and 10 other EMS Associations. These two documents list several pillars that build the foundation for a successful MIH-CP program. These principles are used in the MIH Measures Toolkit to help establish that the program being measured is in fact a formally established MIH-CP program.
Outcome Measures Participants
Participants in the development of the MIH Measures Toolkit includes representatives from EMS organizations such as the National Association of EMTs (NAEMT), the American Ambulance Association (AAA), the National Association of EMS Physicians (NAEMSP), the American College of Emergency Physicians (ACEP), the International Academies of Emergency Dispatch (IAED), the National EMS Management Association (NAEMSMA), the National Association of State EMS Officials (NASEMSO), the International Association of Fire Chiefs (IAFC), the International Association of Fire Fighters (IAFF) and the Paramedic Foundation.
In addition to these organizations, which primarily focus on EMS and emergency medicine, several healthcare quality improvement organizations were included in the process such as, the Institute for Healthcare Improvement (IHI), the National Committee on Quality Assurance (NCQA), the Agency for Healthcare Research and Quality (AHRQ) and Health Insight (a CMS Quality Improvement Network agency).
To assure the measures included a heavy dose of reality, EMS agencies that provide MIH-CP services are also key participants of the project. These included MedStar Mobile Healthcare, University of Pittsburgh Medical Center’s CONNECT Community Paramedic program, the Regional EMS Authority (REMSA), Mesa Fire and Medical Department, Allina Health System, Ada County (ID) Paramedics, Mount Sinai Medical Center, and San Diego Fire-Rescue Department.
With the outcome measures for community paramedic and 9-1-1 nurse triage completed, the measures team is now developing outcome measures for alternative destination transports. This model facilitates the ability for on-scene ambulance personnel to provide an advanced assessment for 9-1-1 patients and, when clinically appropriate, offer them transport to destinations other than an ED.
Additionally, the team is also developing quality improvement and process metrics for the Community Paramedicine service model. This team will develop measures for operational aspects of the programs like number of CP visits by type of patient, case load per CP, referral to enrollment time, etc. These measures can be used to develop benchmarks and best practices for process improvement for the Community Paramedicine intervention.
Join the Movement
Although the MIH Measures Toolkit will continue to evolve over time, it’s crucial for uniformly demonstrating the value of these programs and it will help to establish the long-term economic sustainability of these EMS-based innovations.
We would like to invite agencies offering any MIH service model to participate in both using the current measures, as well as developing new measures. If you would like more information on how to participate, contact any of the authors.
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