High performance health systems of the future have been challenged to create integrated approaches that focus on improving the health of populations, improving the patient experience of care from a quality and satisfaction perspective, and reducing the per capita cost of healthcare. This concept, known as the “Triple Aim,” was first established by the Institute for Healthcare Improvement who launched initiatives in 2007 to bring the concept into action. Many health systems today have adopted strategic goals that are aligned with the Triple Aim in order to optimize system performance.
Why the big push to improve health system performance? According to the Institute of Medicine, it is estimated that 30% of total healthcare spending - approximately $765 billion dollars - goes to unnecessary, wasteful, and ineffective services. One of many reasons emergency medical services contribute to those expenses is that EMS is the safety net provider for the general population, who has been taught to call 9-1-1 because they panic, they are instructed by their professional care takers, or because it is the only most appropriate action. Paramedics have a duty to respond to these calls and provide an assessment, intervention, and transport recommendation. When these services occur, the patient is billed and most ambulance services hope to then get paid.
MedStar Mobile Healthcare, a governmental ambulance agency, is the exclusive provider for emergency and non-emergency services in Fort Worth and 14 surrounding cities in Texas. Averaging approximately 140,000 responses annually, the MedStar system receives a variety of requests, approximately 30% of which require an emergency (lights and sirens) response. A few high frequency users often account for a disproportionate share of 9-1-1 calls and emergency department (ED) visits, many of which were for unnecessary care and represent staff, time, and resources that could have been directed to patients who truly needed services. For example, in 2008, the same 21 individual patients were transported to local emergency rooms over 2,000 times by MedStar, resulting in $962,429 in ambulance charges. A majority of these bills remain uncollected. What if MedStar could direct these patients to a destination other than the ER for non-emergency medical conditions, and reduce unnecessary spending in the process?
In 2009, MedStar created Mobile Integrated Healthcare (MIH), consisting of programs that took a different approach to patient care by collaborating with various stakeholders in the community to provide care using the right resource, at the right time, for the right patient, at the right cost, to ensure the right outcome. MIH serves to fill gaps in patient care and navigate patients to the most appropriate resources using a patient-centric approach.
Readmission Avoidance Program
Over the years, MIH has developed and implemented several collaborative partnerships and programs that work toward successfully navigating patients through the healthcare system. In Fort Worth, these strategic partnerships have been made with local hospitals, home health, hospice, and care management agencies. For hospitals and care management agencies, patients who are at risk for a 30-day admission or readmission are referred to the MIH program by the patient’s case manager, social worker or PCP to reduce the unfavorable outcomes and high financial costs associated with a readmission. Hospitals see the cost associated with enrolling patients in to the MIH programs trivial in comparison to the potential costs and penalties seen with a readmission and the main reason why they are paying for the partnership.
Home Health Program
Through an innovative partnership with local home health agencies, MedStar and the agencies collaborate to provide after-hours and episodic care for home health patients in the event of a 9-1-1 call. Working together, the agency staff and specialty trained paramedics determine the most appropriate care for the patient. Since MedStar has the ability to track 9-1-1 calls made by home health patients, send a specialized paramedic, and work with the agency for the most appropriate care management solution, home health agencies are then able to set themselves apart from the competition by enhancing their service delivery. The agency pays MedStar a fee-for-service or capitated rate.
Hospice Revocation Avoidance Program
MedStar was approached by several hospice providers in the Fort Worth area to help try and reduce the incidence of revocation for patients on home hospice, leading to the creation of the Hospice Revocation Avoidance program. Enrollment and disenrollment in hospice is frequently an emotionally taxing process for all involved, including EMS and hospital personnel. Hospice agencies can accurately predict patients who are at-risk of dis-enrolling in hospice services due to a perceived emergency by calling 9-1-1. These events often occur during a moment of panic in the dying process and may be precipitated by family members who may not agree with the care plan of the patient. In partnership with hospice agencies, MedStar will enroll high-risk revocation patients in to the MIH program. These patients are identified at the time of their 9-1-1 call and a specialized paramedic is deployed to the scene. The paramedic will then work with the hospice agency to coordinate care that is in-line with the patient’s hospice care plan with the overall goal of reducing a revocation from the program. Payment is set up such that MedStar will receive an outcome-based fee (i.e. if revocation is avoided and the patient remains at home), a per patient, per month fee, or capitated rate.
High Utilization Program
The paramedics will also conduct scheduled, proactive visits in the patient’s home for the high frequency and readmission avoidance patient population. During home visits, the paramedic provides a medical and environmental assessment, ensures that the patient is taking their prescribed medications, has transportation resources, is following up with their PCP, and provides education on disease management and diet. The paramedics will develop individual care plans or reinforce previous plans to ensure the length of time in the program is meaningful for both the patient and the provider. Patients are given specific goals that relate to their health and graduate from the program once those goals have been met. If a patient has identified gaps in their care related to transportation, the organization has a partnership with Lyft and will set up rides to and from doctor’s appointments with the goal that by the end of enrollment, the patient will have the resources in place to arrange transportation on their own.
Evaluating MIH program success is captured in several ways. For the High Utilization program, a comparison of ambulance, emergency room, and admission costs for enrolled patients based on utilization 12 months prior to enrollment versus 12 months post program graduation is analyzed. Since July 2009, MIH has reduced ambulance transports to the ED for 535 patients with 1-year pre- and post- enrollment data by 5,009 (59.7%). It has also reduced ED visits in this patient population by 2,395 and prevented 462 hospital admissions. This reduction has saved $9.27 million in healthcare expenditures for ambulance, ED, and admissions.
For the Readmission Avoidance program that began in 2013, 295 patients who had a 30-day readmission and the referring agency felt would have a readmission have been referred in to the program. Of those, only 140 had a 30-day readmission, a 52.5% reduction in readmissions for this high-risk readmission cohort.
MedStar also conducts both external satisfaction surveys and health status surveys on all patients who have completed the High Utilization and Readmission Avoidance program. The satisfaction surveys evaluate the paramedics, quality of care, patient’s understanding of instructions, compassion, and overall satisfaction with the program. The health status surveys assess the patient’s perception of their mobility, self-care, usual activities, pain, anxiety or depression, and overall health status. For patients in the High Utilization program where pre- and post- surveys were conducted, there was a 39% improvement in overall health status. For patients in the Readmission Avoidance program, there was a 29.5% improvement in overall health status. Paramedics play a vital role in improving outcomes by filling gaps in the healthcare system, whether it’s providing care for patients who don’t otherwise qualify for services (like home health or rehabilitation) after a hospital admission or assisting in care coordination for a hospice patient during the time of a 9-1-1 call. MIH provides integrated post-acute care, chronic care, and prevention services on a 24-hour a day basis and is quickly becoming the wave of the future for EMS providers. The days of “you call, we haul” are a distant memory in EMS as MIH continues transform care delivery through strategic partnerships and innovative programs that work to improve population health, enhance care, and reduce costs.
Desiree Partain is the clinical program manager at MedStar Mobile Healthcare in Fort Worth, TX. She is a critical care paramedic with 13 years’ experience in EMS and five years as a mobile healthcare practitioner at MedStar. MedStar was named the 2013 Paid EMS System of the Year by NAEMT and EMS World. Its MIH-CP program is profiled in the AHRQ's Healthcare Innovation Exchange.
“The IHI Triple Aim,” Institute for Healthcare Improvement, www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx.
Institute of Medicine. Interim Report of the Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Care: Preliminary Committee Observations. Washington, DC: The National Academies Press, 2013. https://doi.org/10.17226/18308.
“MedStar Mobile Healthcare,” MedStar Mobile Healthcare | Serving Fort Worth, TX & Surrounding Communities, www.medstar911.org/.