MedStar’s community health program translates into better care for less cost
Very few things in EMS are certain, but most experts have long agreed that the basic model of how EMS is provided needs to change. Historically, we’ve focused on providing a quick response to episodic events. Arguably, most EMS systems in the country have been designed to provide a BLS response to cardiac arrest victims within four minutes, and an ALS response within nine.
Although this goal is admirable, it only addresses 1% of our response volume. (I won’t go into whether these standards have resulted in any demonstrable difference in the outcome of cardiac arrest victims.) What about the 85% of responses that any seasoned EMS veteran will tell you don’t require an emergency department visit and arguably don’t warrant an ambulance?
The concept of preventing the EMS call before it occurs has been the subject of folklore since NHTSA published its EMS Agenda for the Future in 1996. Although many EMS systems have contemplated how this might work, a rare few have actually implemented programs. Those include Wake County (N.C.) EMS Systems and Western Eagle County (Colo.) Ambulance District. Additionally, MedStar in Fort Worth, Texas, has embarked on its own community health program and has seen phenomenal results.
Grounding “˜frequent flyers’
Facing the dog days of summer and the commensurate rise in call volume it brings to our urban EMS system, in July 2009 MedStar began proactively managing the top 1% of “frequent flyers.” These 21 patients represented more than 820 EMS responses and emergency department admissions over the previous 12 months. Our analysis found that many of these patients had easily managed medical or psychiatric issues. If we could take these unnecessary responses out of the EMS system, we could better meet the needs of our community, improve patient health and save the system a lot of money.
MedStar’s Medical Director Jeff Beeson, DO, worked with several patients’ primary care providers to collaboratively develop care plans that met their needs. Specially trained advanced practice paramedics now visit the patients on a scheduled basis.
The APPs teach patients how to more appropriately navigate the health-care system. (In one case, that meant literally helping the patient navigate the public transportation system to get to their doctor’s office.) They show patients how to better care for themselves and troubleshoot to prevent unnecessary 9-1-1 calls.
The patients are given a non-emergency number to MedStar’s communications center, through which they can either speak with the on-duty APP or request a home visit. Other agencies, our hospital partners and our own employees can refer patients to the program for evaluation and inclusion.
To date, 64 patients have been referred to the community health program. Many have “graduated,” meaning they’re no longer “frequent flyers” and now manage their own care. In the first full year of the program, we reduced 9-1-1 and ED use by the referred patients by 67.4%. That translates into an estimated $540,000 in unit hour cost savings and $640,000 in ED savings.
The insurers–and those of us who pay premiums–benefit as well: The program has saved an estimated $2 million in billed ambulance charges and $5 million in billed ED charges. We’ve also returned approximately 9,072 bed hours to our local EDs, which means shorter waiting times for patients and ambulance crews. Better yet, the patients are healthier.
Preventing CHF “˜bounce back’
A natural spin off the community health program began when local cardiology groups quickly discovered how this program could help patients and cardiologists. Congestive heart failure patients are generally at a high risk of “bounce back” after hospital discharge, especially if they’re returning to a medically or socially challenging environment.
What’s more, in some cases, if the patient returns to the emergency room within 30—45 days (the “bounce back”), the costs associated with their care or readmission is borne by the cardiologist and discharging hospital. The concept is to help prevent patients from being prematurely discharged to save money. These sorts of penalties are expected to increase under health-care reform, as reimbursements will be tied to quality of care.
Under MedStar’s CHF program, the discharge case managers refer at-risk CHF patients to us, and an initial home visit is scheduled the day of the patient’s hospital discharge. We offer our services to the patient, and if they accept, they’re scheduled for APP home visits two or three times per week. At present, these services are provided at no cost. However, several organizations have indicated their willingness to fund the program once we’ve demonstrated cost savings.
During these visits, the APP assesses the patient for signs of worsening CHF (lung and dependent edema checks, weight measures and 12-lead ECGs) and overall medication and diet compliance, including refrigerator checks. If the patient’s condition appears to be deteriorating, the APP can set up an office appointment for the patient with the primary care physician or cardiologist–before they end up in the ED or calling 9-1-1. We currently have four patients in the CHF program.
As a demonstration of the program’s value, during our very first CHF patient visit, the patient related how hard it was to walk up the three flights of stairs to his apartment. At this first visit, the APP contacted the apartment manager and made arrangements to have the patient moved to a first floor apartment, averting potential disaster and making the patient more comfortable.
The program likely saved another CHF patient’s life. One morning in September, the APP called to check on a patient in our CHF program. The patient relayed that he had fallen during the night and, although was back on his feet, was feeling weak. The APP visited the patient at home and did a full assessment. The patient was found to be having an acute anterior wall myocardial infarction, and an ambulance was summoned to take him to the cath lab at his medical home.
A day after reperfusion and stent placement, the patient was home and doing great. The case manager feels that a few hours in this patient’s case made the difference between life and death.
Fast-forward to the day when an accountable care organization (as envisioned in health-care reform) meets with you to decide if your EMS agency makes a difference in patient outcomes, as required for reimbursement. Is your agency ready for that discussion? Can you demonstrate a difference in your patients’ outcomes based on the service you are currently providing? At MedStar, we’re ready to answer the question: “Does your service make a difference in your patient’s outcomes?”
Setting up a community health program is easier than you might imagine. For more information on the MedStar program, including turn-key documents, protocols and up-to-date program statistics, visit www.medstar911.org/community-health-program. To read the EMS Agenda for the Future visit www.ems.gov.
