The Time Has Come for Mobile Integrated Healthcare

There’s been a lot of buzz about mobile integrated healthcare (MIH) throughout the EMS community. Because we believe this new aspect of EMS will expand and become part of every agency in the future (to some degree), we’ve introduced a new article series that focuses on MIH’s inner-workings.

Much different than what others are presenting, JEMS will focus on the positive impact and results of MIH efforts. In our first article of the series, “Imparting Knowledge & Restoring Hope,” by Matt Zavadsky, MS-HSA, EMT, readers will, for the first time
in any publication, see MIH from the patient’s perspective.

Antoine Hall, a patient who graduated from the “frequent flyer” program at MedStar in Fort Worth, Texas, explains how he learned not only how to better manage his multiple illnesses, but more importantly, how to live.

Zavadsky also details the resource costs Hall’s turnaround saved the MedStar system and its partner hospitals–an important aspect of MIH programs. We’ll do this in all of our MIH articles for you.

JEMS refers to this overall progression as “mobile integrated healthcare” because MIH is a cohesive process involving multiple agencies and personnel. And, while many are referring to the providers in this new clinical and operational practice as “community practice paramedics” or “advanced practice paramedics,” there are now EMTs, paramedics, firefighters, registered nurses, nurse practitioners, physicians assistants and physicians involved in the delivery of this new system of triage and care. Therefore, we’ll refer to the providers as “mobile healthcare providers” (MHPs).

MIH isn’t a new EMS practice, but rather an extension of what many services have been providing for a long time. Joe Ornato, MD, medical director of the progressive Richmond Ambulance Authority in Virginia, summed it up best, saying: “We don’t offer a community paramedic program. We have paramedics in the community and have offered specialized services to our residents for years.”

I’ve always been a fan of the Phoenix (Ariz.) Fire Department’s (PFD) approach to customer service, encouraging crews to provide “custom” services to residents outside traditional fire, medical and trauma services. At fire scenes, the PFD encourages crews to spend extra time covering and protecting personal property during overhaul. Crews even clean up debris from residents’ lawns to allow a family to return to some degree of normalcy after a devastating fire.

Like the PFD, the Orange County (Calif.) Fire Authority and many other agencies have allowed their crews to assist patients back into bed, get food for the patient, or retrieve medications from a pharmacy. Indirectly, this provides care for the patient, prevents their preexisting conditions from worsening, and reduces unnecessary responses, patient transportations and ED overcrowding.

When I was the operations director at Cetronia Ambulance in Allentown, Pa., we would send ambulances with snow chains on to pick up ED staff members at their homes during snowstorms to get them to their hospitals. While not a revenue source for us, it was a service that helped us keep the EDs from being understaffed during the storms and, consequently, prevented crews from being tied up at backlogged EDs.

One day, a dispatcher referred a call to me from a woman whose family purchased an annual subscription from us to ensure they received special services and transportation when necessary. The woman’s husband was out of town with their only car and she was trapped in her home by a snowstorm, unable to get baby formula for her newborn. So, I asked one of our crews to call her, determine what brand and quantity of formula she needed, purchase it at the store of her choice and bring it to her. The crew politely questioned if this task was in the purview of their role in EMS. I explained my rationale and they dutifully performed the service.

When the husband returned from his business trip and learned about the extra services rendered to his family, he sent a $100 donation with a note expressing his gratitude our agency went “above and beyond the scope of what we normally do.” Even if the type of community service doesn’t directly channel money into your coffers, it will often reap you tremendous benefit whenever you need community support for the increase in municipal subsidies or allocation of funds for new personnel, vehicles or facilities.

And, in an era of reduced reimbursements and call volume, MIH is a way to drive new revenue. Some services experiencing reduced call volume revenue from “Obamacare” will realize over $2 million next year in revenue from contracts with hospitals, home health and hospice agencies, and healthcare payers.

The services being provided by organizations formally deploying MHPs, in general, are simply finding new ways of utilizing existing protocols within their scope of practice and procedures, and enhancing community services. What many systems are doing really only requires legislation changes if you want special state reimbursement for non-funded services or if your law specifically prohibits MIH practices. If this is the case, I believe legislators, if properly informed, will support changing the law. They did it in Minnesota, Maine and Tennessee. Other states will follow.

There’s also no one specific mold for MIH, but rather customized approaches to a community’s needs. Some systems are focusing, commendably, on addressing those in need of psychological services and referral. In some parts of the country, volunteer agencies and services of all sizes are partnering with their local healthcare networks to develop an MIH system that covers all service areas.

This is going to be an increasing need for EMS, especially with the large number of armed services members returning to civilian life with post-traumatic stress and traumatic brain injury issues. Crews will need to slow down the tempo of the calls to spend more time than normal to provide guidance and care in a nontraditional manner to depressed and suicidal veterans desperately in need of attention and special referrals.

Some systems are focusing on the reduction of EMS system abusers. This is an important task for all services to become involved with, first analyzing their top 100 system users and then addressing ways to get them away from excessively calling 9-1-1. The San Diego Resource Access Program is a perfect example of how a system can help the homeless and system abusers. (Read the January 2013 JEMS article, “San Diego’s eRAP System Redirects Frequent Flyers,” for more information.)

There’s been some resistance by the fire service and the International Association of Firefighters to embrace this new public safety role, fueled by concerns of unionized nurses who feel their jobs will be threatened. I can remember when the nursing community felt threatened by–and objected to–paramedics. Those fears were unfounded and EMS had little effect on the nursing community.

The same will occur with MIH because nurses, particularly the visiting nurse associations, aren’t enthusiastic about responding to patient homes after midnight and on weekends. In MIH programs such as MedStar’s in Fort Worth, three nurses are employed full time in their service delivery model. Presented in the right way, MIH programs not only achieve the Institute for Healthcare Improvement’s Triple Aim (improving the patient’s experience of care, improving population health and reducing costs), but adds a fourth benefit–expanding the career ladder for registered nurses and other inter-professionals, as well as for EMTs and paramedics who want to have a large impact on patient’s lives.

The fire service should embrace the concept as they did with fire prevention decades ago. Sure, fire inspections and changes in building codes and sprinkler requirements reduced fire calls significantly, but it also created a lot of new jobs for firefighters who landed day jobs as fire inspectors.

The same thing can also happen with MIH in the fire service. Seasoned employees who’ve strained their backs for years carrying patients down hundreds of stairs can become MHPs and respond to community needs in a specially equipped vehicle during the day shift.

Naysayers need to wake up and smell the coffee, because if they don’t get involved in this new community service, other entities will. Experts predict that as patients are carefully monitored and managed at home and call volume is reduced, EMS revenue will drop. In those cities where the fire service isn’t involved in this new era of preventative healthcare services, city officials will question the need to maintain staffing at current levels.

It’s a new era for EMS. Financial stakeholders are blatantly balancing the value equation and we all too often end up on the wrong side. Learn how to transform your agency into one that truly demonstrates value to your community with each of the special articles in this new series.

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