ems mobile integrated healthcare - new england …€“ integrated ems/home health inter ntion •...

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Home Health and EMS-Based

Mobile Integrated Healthcare

Shotgun Wedding

or

A Match Made in Heaven

© 2015 MedStar Mobile Healthcare

What we’re gonna do…

• The “Why”– Analyze the current state of the US Healthcare system

• Special focus on Home Health and Hospice issues

• The “How”– “EMS” and home health/hospice can and are collaborating

• How could that fit in your world?

• And –– Learn certain words that have a whole different meaning

in Texas…

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Summer:• What it means everywhere else: A time for vacation, road

trips, and fun in the sun.

• What it means in Texas: Hell on Earth where the temperatures

rarely dip below 100 degrees.

About MedStar…• Governmental agency (PUM) serving Ft. Worth and 14 Cities

– Self-Operated

– 880,000 residents, 421 Sq. miles

– Exclusive provider - emergency and non emergency

• 117,000 responses annually

• 450 employees

• $37.5 million budget

– No tax subsidy

• Fully deployed system status management

• Medical Control from 14 member Emergency Physician’s

Advisory Board (EPAB)

– Physician Medical Directors from all emergency

departments in service area + 5 Tarrant County Medical

Society reps

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Our World is Changing:

Attention Please!

• $9,255 per capita health expenditures!!

– Due in large part to quantity-based payments

http://kaiserhealthnews.org/news/health-costs-inflation-cms-report/

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Our New Environment:

• Steroid Injection = ACA– ACOs (523 as of April ‘14)

• 368 Medicare

• 155 Commercial Insurer-based

• 31 million covered lives

– Payment based on OUTCOMES

– Bundled payments based on episode of care

– Push to Managed Medicare/Medicaid

– MSPB calculations = 2015• Medicare Spending Per Beneficiary

– Hospital accountable for some outpatient post acute costs

http://www.beckershospitalreview.com/accountable-care-organizations/total-number-of-

acos-tops-520.html

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HHS Pledges To Quicken Pace Toward Quality-Based Medicare PaymentsBy Jordan Rau January 26, 2015

The Obama administration Monday announced a goal of accelerating changes to

Medicare so that within four years, half of the program’s traditional spending will go

to doctors, hospitals and other providers that coordinate their patient care,

stressing quality and frugality.

The announcement by Health and Human Services Secretary Sylvia Burwell is

intended to spur efforts to supplant Medicare’s traditional fee-for-service medicine,

in which doctors, hospitals and other medical providers are paid for each case or

service without regard to how the patient fares. Since the passage of the federal

health law in 2010, the administration has been designing new programs and

underwriting experiments to come up with alternate payment models.

“For the first time we’re actually going to set clear goals and establish a clear

timeline for moving from volume to value in the Medicare system,” Burwell said

http://kaiserhealthnews.org/news/hhs-pledges-to-quicken-pace-toward-

quality-based-medicare-payments/

Truck:

What it means everywhere else: A machine used for hauling heavy

loads.

What it means in Texas: Every other vehicle on the road.

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PCPs are in shortest supply in low-income, low-insured areas, many of which are rural

communities. Several solutions and existing best practices could address these

issues, however:

• Value-based payment models: Payment systems that provide incentives for value

and outcomes over intensity of service "are fundamental to increasing primary care

capacity and improving the effectiveness and efficiency of service delivery," the

report states. This could include performance-based bonuses linked to quality

benchmarks or risk-adjusted monthly payments for primary care.

• Expanded responsibilities for nurse practitioners (NPs) and physician assistants

(PAs): Leveraging non-physician clinicians can help practices expand capacity,

according to the report. This is demonstrated by expanded scope of practice for NPs

and PAs in several states, including New York and Kentucky.

• Multidisciplinary care teams: To further distribute their workload, PCPs must also

expand responsibilities for professionals such as health coaches and medical

assistants. Such multidisciplinary efforts historically improve outcomes and cut

costs, according to the report.

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CMS Bonuses/Penalties…

• Readmissions (up to 3%)– 2013-2014

• MI

• CHF

• Pneumonia

– 2015• COPD

• Hips/Knees

Medicare Fines 2,610 Hospitals In Third Round Of Readmission

PenaltiesBy Jordan Rau

KHN Staff Writer

Oct 2, 2014

Medicare is fining a record number of hospitals – 2,610 – for having too many

patients return within a month for additional treatments, federal records released

Wednesday show. Even though the nation’s readmission rate is dropping,

Medicare’s average fines will be higher, with 39 hospitals receiving the largest

penalty allowed, including the nation’s oldest hospital, Pennsylvania Hospital in

Philadelphia.

Under the new fines, three-quarters of hospitals that are subject to the Hospital

Readmissions Reduction Program are being penalized. That means that from Oct.

1 through next Sept. 30, they will receive lower payments for every Medicare

patient stay — not just for those patients who are readmitted. Over the course of

the year, the fines will total about $428 million, Medicare estimates.

http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-readmissions-penalties-

2015.aspx

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Medicare uses the national readmission rate to help decide

what appropriate rates for each hospital, so to reduce their

fines from previous years or avoid them altogether, hospitals

must not only reduce their readmission rates but do so better

than the industry did overall.

"You have to run as fast as everyone else to just stay even,"

Foster said. Only 129 hospitals that were fined last year

avoided a fine in this new round, the KHN analysis found.

Medicare officials, however, consider the competition good

motivation for hospitals to keep on tackling readmissions and

not to become complacent with their improvements.

http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-

readmissions-penalties-2015.aspx

The all-cause 30-day hospital readmission rate among Medicare fee-for-service

beneficiaries plummeted further to approximately 17.5 percent in 2013,

translating into an estimated 150,000 fewer hospital readmissions between

January 2012 and December 2013.

This represents an 8 percent reduction in the Medicare fee-for service all-cause

30-day readmissions rate.

http://innovation.cms.gov/Files/reports/patient-safety-results.pdf

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CMS Bonuses/Penalties…

• Value-Based Purchasing (up to 1.5%)

– Clinical process of care (12)

– Patient experience (8)

– Healthcare outcomes (5)

– Efficiency (1)

Value-Based Purchasing…

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Packing:

What it means everywhere else: Putting stuff away in

preparation of a move.

What it means in Texas: How much firepower you’re

carrying.

EmergencyMedical

Services?

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“EMS?”

• 9-1-1 safety net access for non-emergent

healthcare– 35.6% of 9-1-1 requests

• 12 months Priority 3 calls (44,567 (P3) / 124,925 (Total))

• Reasons people use emergency services– To see if they needed to

– It’s what we’ve taught them to do

– Because their doctors tell them to

– It’s the only option

• 37 million house calls/year– 30% of these patients don’t go with us to the hospital

2012 NASEMSO Report

“EMS?”

Call Type % Increase

Interfacility 11.32%

Sick Person 10.37%

Falls 5.87%

Unc Person 5.20%

Assault 4.21%

Convulsions 4.16%

Psyc. 3.76%

Call Type % Decrease

Abd Pain 2.83%

Traum Inj. 3.71%

Chest Pain 7.97%

MVA 10.38%

Breath. Prob. 10.48%

10-year % change of overall call volume…

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EmergencyMedical

Services?

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UnscheduledMedical

Services!

Our Role?“Emergency medical services (EMS) of the future will be community-

based health management that is fully integrated with the overall

health care system. It will have the ability to identify and modify

illness and injury risks, provide acute illness and injury care and

follow-up, and contribute to the treatment of chronic conditions

and community health monitoring. This new entity will be

developed from redistribution of existing health care resources and

will be integrated with other health care providers and public health

and public safety agencies. It will improve community health and

result in more appropriate use of acute health care resources. EMS

will remain the public’s emergency medical safety net.”

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Football:

What it means everywhere else: A popular American team sport.

What it means in Texas: Religion.

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Current State of Home Health

• Financial Penalties for Readmissions

• Hospitals Today � Home Care in future

• CENSUS AND CARE PLAN INTERRUPTIONS

• Educate the patient Call Your Nurse

•…911 (panicked patients and families)

• EMS Working against Home Care

• Paid for Transports to Hospital

Home Care Desired State –EMS Partnerships

• Incentives congruent with EMS

• Home Care Notified when Patients Calls 911– Integrated EMS/Home Health Intervention

• Home Care Medical Dir. & EMS Medical Dir.– Integrated Protocols and Procedures

– Patient Case Conferences & Shared EMR

• Reduce Hospitalizations & Increased Referrals

• Quality Performance Improvement

• Health Care Savings

• Business Development

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Stars Align…

• Home Health– Reduce unnecessary ED visits

• Increase hospital referrals

– Reduce unnecessary admissions/readmissions• Increase hospital referrals

– Know when patients call 9-1-1

– Bridge from referral to 1st home health visit

– After hours coverage

– Referrals from EMS-MIH providers• When patients qualify

How it Works – Home Health

• Klarus registers patients in MedStar service

area

• Patients entered into 9-1-1 dispatch system

• EMS EMR created with basic information

• Interface login with Kinser for EMS-MIH

providers

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• If patient calls 9-1-1…

– Ambulance and MHP respond

– Klarus on-call nurse notified of response

– MHP arrives and assesses patient

– Calls Klarus nurse for consult/disposition coordination

– If medical orders, agreed protocols

• Foley, wound vac, diuresis, COPD, hypoglycemia

– Treat and refer, or treat and transport

• If requested by Klarus

– On-scene support and care coordination


• If other MIH program referral meets home

health enrollment criteria– Klarus preferred provider

• Other relationships � referrals

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Response:Outcome Analysis

Klarus

As of: 3/31/2015

Enrollments 553

Emergency Calls 275 49.7%

Emergency Calls w/o MHP on scene 154

Transports w/o MHP on scene 133 86.4%

Emergency Calls w/MHP on scene 121

Transports w/MHP on scene 47 38.8%

Home Health Data (2/14 – 3/15)

• 92 Visits Requested by Klarus Home Care

– Primarily after hour “Crisis”

– 0 transports

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Klarus Home Care – Case #1• PATIENT SITUATION:

– 68 Year Old Obese Female living in Extended Stay Hotel

– DX DMII uncontrolled

– New Admit, County Hospital Referral, No Dr. of Record, No Sliding Scale Orders

– RN visit in day time BS 500 no distress symptoms, Administered Victoza 1.2 mg

• FOLLOW UP INTERVENTION REQUESTED BY KLARUS RN:– MedStar Advance Paramedic makes a after hours visit to patient

– BS 350, Paramedic consulted with on Call RN

– Paramedic Consulted with EMS Medical Director

– Medical Director advised to increase water input for tonight

– RN follow up next day consulting MedStar

– MedStar used Taxi voucher to transport patient to County Clinic New Orders

• OUTCOME:– Patient not transported to Emergency Room

– Patient safe and BS monitored after hours

– Patient utilized non emergency transport Dr. to obtain New Sliding Scale Orders

Klarus Home Care – Case #2• PATIENT SITUATION:

– 67 Year Old Male, DX: Cardiomyopathy, Chronic Sys Heart Failure, Pleural Effusion, DMII,

– Exacerbation of CHF 2x in last 60 days TX by RN using Klarus CHF Protocols 40 mg IV

Lasix

– Patient calls Ambulance after hours due exacerbation. Does not call Home Health

• FOLLOW UP INTERVENTION REQUESTED BY KLARUS RN:– MedStar Advance Paramedic identifies Patient as Klarus Patient, Calls RN on Call in

Route to House

– Assessment reported to RN: Patient Short of Breath, Legs swollen edema 3+

– RN Advised MedStar to Use CHF protocol & Administer 40 mg IV Lasix

– MedStar verifies CHF orders in Klarus Electronic Medical Record & Consults EMS Medical

Director

– IV Lasix administered

– MedStar provides follow up visit later that night checks potassium, consults on call

physician, and adjust the potassium

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Klarus Home Care – Case #2

• OUTCOME:

– CHF Patient not transported to Emergency Room

– CHF exacerbation signs and symptoms eliminated

– Coordination with Klarus & Use of Protocols prevents unnecessary

Hospitalization

– Health Care Cost Savings $9,203

Client: XXXX, Barry - 1952-XX-XX

Program: Home Health - 911

Status: Active

Referring Source: Klarus

DSRIP Client: No

Visit Date: 11/27/2014 14:02

Visit Type: Home Visit

Visit Acuity: Unscheduled Visit

Visit Outcome: MHP Call Complete

Klarus called for us to go out and check Pt's cath. relayed it was leaking. upon

arriving on scene, Pt relayed pain. wife relayed she had not noticed any leaking.

first the bulb was deflated. 7cc's of fluid pulled out. some urine voided after

deflation from around the cath. Cath was advanced approx 2inches and re-

inflated with 10cc's of fluid. Pt confirmed relief of his pain. Told him to call back

if he started having pain again. The only other option will be to remove the cath.

The urine was dark yellow. No sediment noted.

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EMS/MIH Case Study #1 – Home Health

Client: XXXX, Barry - 1952-XX-XX


Status: Active


DSRIP Client: No

Visit Date: 11/27/2014 17:45




Client called back because he was sWll hurWng. Made scene and

removed cath. No problems removing. he immediately felt

better and relayed no pain again. He urinated into a urinal so

there may have been a blockage in the cath itself. Called and

discussed with Klarus for follow-up visit PRN.

Program: Home Health

Status: Active


Visit Date: 11/27/2014



Transport Resource: N/A

Note:

Arrived on scene per Klarus request to stop wound vac and place a wet to dry dressing

due to blockage on wound vac. Upon my arrival client met us at the door in good

spirits. She explained her wound vac started with an error message which read

blockage. She did have a blockage in the tubing closest to the pump itself. I clamped the

tubing and turned the vac off then opened the tubing, re-secured the tubing then

unclamped it and turned the pump back on; the blockage immediately cleared. I waited

with the client for about ten minutes to see if the problem was solved. I provided client

with our non-emergency number in the event it occurred again we would then place a

wet to dry dressing. I contacted the after hours number for Klarus and spoke with

Diana. I left all of the material for the wet to dry dressing in the clients home. Visit

Complete. MHanson

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From: MHP Clients [mailto:[email protected]]

Sent: Saturday, April 11, 2015 11:26 AM

To: Monica Cruz; Darla Kemp; Matt Zavadsky; Sherry Willingham; Susan Swagerty

Subject: MIHP Note - Source: Klarus - Program: Home Health - 911

Client: XXXXX, Joycia Y – 19XX-XX-XX



Visit Date: 4/11/2015


Visit Acuity: 911 Call

AOSTF pt. lying on couch in NAD. Crew reports pt. has been having CP since last night and is

mid sternal and radiates to her back, rates at 9/10. Her pain is worsened by movement and

breathing. Her V/S are reported to be stable and she is reported to be a little anxious. In

speaking with the pt. she agrees with the crews report of the situation. She also reports she

has had a 10lb weight gain since yesterday according to her Cardiocom unit. She has had

this in the past and this is the same pain she usually has. She believes her NTG will relieve it

but she was afraid to take as Klarus usually walks her through it. She also has an anxiety

history and has not taken her Xanax or other morning meds yet. Pt. denies any N/V or

diaphoresis.

She also feels like her hands and feet are swollen as they feel tight. She denies

additional complaint. Upon exam noted pt. in NAD. Pt. is A&OX4, PPTE, MAE.

VSS. BSCB, non labored. SR on 12-lead w/o acute changes. No edema is noted to

hands and very mild edema noted to top of her feet once socks removed. I spoke

with Diana at Klarus regarding this pt. I reported her complaints. I did advise her

about the weight gain. She felt pt. should take her NTG. She also reports pt.

has been to the hospital for this in the past and was ruled Anxiety those times.

Pt. reported dramatic improvement in the discomfort after the NTG. Pt. was

advised we could not R/O cardiac involvement without blood work but pointed

out what we found on exam. Pt. opted to take her morning meds and stay at

home.

As we were getting ready to leave Diana called back and reported her weight

had in fact increased by 10 lbs. over the last 24 hours and would like her to be

diuresed. I relayed this to the pt. and she agrees to plan.

A Chem 8 was obtained and her K+, Hct and Hgb was noted to be low.

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I spoke with Dr. Davis regarding the Potassium dosing since she was a little low

and he advises to increase her Potassium from 40 mEq Bid to 40mEq Tid today

only.

IV was initiated and Lasix 100mg IV was given SIVP. Pt. was advised to

monitor and record her urine output using the hat she was provided and we

would see her at 1400 for a F/U. If anything changes to call Klarus or us back.

Pt. remains pain free upon departure.

I again spoke with Diana and advised of the treatment and that she would

need a visit from them within 24 hrs. by protocol and she was going to get that

set up. Visit complete.

Austin:

What it means everywhere else: The capital of Texas.

What it means in Texas: A completely different planet.

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Hospice Referral

• Trusted hospital partner refers hospice eligible patient

• Commitment to response made

Evaluation & Admission

• Patient appropriate for care

• Admission completed/family educated but remain anxious

Revocation

• Significant change in condition

• Family panics and calls 911

• First Responder returns patient to trusted hospital partner ER

• Readmission to trusted hospital partner ER

• EMS charge of $800

• ER Charge of $3500

• Decreased Revenue of $7104

Loss of

• Census

• Revenue

• Trusted

Hospital

Partner

Mobile Integrated Healthcare

Hospice Referral

Evaluation And Admission

Family Anxious/Calls 911

• Retention of ADC

• Increased Family

Satisfaction

• Increased FEHC

Score

• Less expenses

• No loss of Revenue

• Increased Trust

with Hospital

Partner

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Stars Align…

• Hospice

– Prevent unnecessary ambulance transports

– Prevent unnecessary ED visits

– Prevent unnecessary acute care admissions

– Prevent voluntary disenrollments

– Prevent revocations

Framing the Hospice Issue:

• Patients & families want patients to die

comfortably at home

• Hospice wants the patient to die at home

• Death is scary

• When death is near….

• 9-1-1 usually = Hospice Revocation

– Voluntary or involuntary

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Economic Model

• Hospice benefit– Per diem from payer to agency

– Agency pays hospice related care

– LOS issues

– Varies based on Dx

• MedPAC recommends increasing hospice

benefit

• IHI recommends increase hospice enrollment

How it Works - Hospice

• Patients/Families ID’d by VITAS as ‘at-risk’ for

9-1-1 call

• Referred to MedStar program

– Entered into 9-1-1 system

• Joint initial home visit with hospice RN &

MedStar

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• In case of 9-1-1 call

– MHP co-responds with ambulance

– Comm Center calls on hospice RN while enroute

Ambulance and MHP arrive

– If call not related to hospice plan of care

• Handle as usual


• If is part of plan of care

– Calm and reassure family

– Make patient comfortable

• Access prescribed comfort pack

– Assess and call hospice nurse

– Determine disposition

• Await RN

• Release ambulance

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– If ‘really bad’

• Arrange for in-patient hospice transfer

• Referrals from other programs (CHF)

– Stage 4 CHF

– Conversation project

– Refer to VITAS after family agrees to palliative care

Hospice Program SummarySept. 2013 - March 2015

# %

Referrals (1) 209

Enrolled (2) 176

Deceased 133 75.6%

Active 21 11.9%

Improved 2 1.1%

Revoked (3) 20 11.4%

Activity:

EMS Calls 55

Transports 34

ED visits 27

Direct Admits 7

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EMS/MIH Case Study #1 – Hospice

XXXXXX, Sybil W 89 Years (Actual) Female 126 Lbs Ethnicity: Caucasian

Chief Complaint: Breathing Problem (Medical);

Working Diagnosis: VITAS Client

COMMENTS

VITAS Hospice Client - 911 call

Dispatched on p1 breathing difficulty. Arrived on scene to find 89 YO WF home

alone. Client relates she became anxious and short of breath. Client relates she is

unable to move from chair to turn on her oxygen on her own. Client appears to

be weak with limited mobility due to her advanced Parkinson's. Client's

paperwork for VITAS is laid out on the table with her signed DNR. Client relates

she has around the clock care with providers provided to her by her family. She

lives with her son and his spouse but they leave Saturday mornings and are not

generally back till the afternoon. Client relates her caregiver is off for today and

she is supposed to have a substitute arrive at 11 am but they are late.

EMS/MIH Case Study #1 – Hospice

I spoke with Helen, the triage nurse with VITAS and discussed the situation with

her. The client is on her oxygen and relates prior to my arrival she took

something for her spasms but was unable to determine what it was she took.

Client relates she feels much better now that she has her oxygen on. I waited for

caregiver to arrive and explained the situation. The caregiver wrote me a note

stating 'she thinks she is short of breath but she really isn't'. I explained it could

very well be anxiety, but having the oxygen on improved her saturation.

She stated she understood. She also spoke with Helen the triage nurse. Ms. XXXX

relays to me she is fine now that Kate, the families friend who is her caregiver, is

there. I left our number with Kate and made sure

Ms. XXXX had her med alert necklace on. Visit Complete. MHanson

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EMS/MIH Case Study #2 - Hospice

XXXX, Ernest J 81 Years Male 303 Lbs Ethnicity: African-American

Chief Complaint: CHP Visit;

Working Diagnosis: CHP Visit

COMMENTS

Arrived on scene I found crew about to move the patient onto the stretcher. I

requested they wait until I could call Vitas and discuss the case with them.

I then spoke to the family and let them know we were going to contact Vitas and

discuss the patient with them. I also asked them about why they had called 911.

Daughter reports the patient was seen today by a physician and was told he had

decreased urinary output and should be seen for that. She decided to call 911 to

send the patient to the hospital to be evaluated for possible dialysis.

EMS/MIH Case Study #2 - Hospice

I spoke to Vitas and advised them we were on scene. I also told

them the patient's family agreed to wait until the nurse to arrive

to decide on transport, so they dispatched a nurse. I released the

ambulance at that point.

I waited on scene until the nurse arrived. I turned care over to

her and gave a basic report regarding why we had been called,

along with vital signs. She then evaluated the patient and spoke

with the family. The decision was made to treat the patient at

home. I then cleared the scene.

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EMS - Current State

• Reactive vs. proactive

• “You call, we haul, that’s all”

• Paid only to transport

– Only eligible destination is ED

– When all you have is a hammer….

• Limited integration of the healthcare system

• “Pre-Hospital” care

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• Right Resource

• Right Time

• Right Patient

• Right Outcome

• Right Cost

EMS - Desired StateMobile Integrated Healthcare

EMS-MIH/Home Health &

Hospice Partnerships

• Fill gaps– Refer to enroll gap

– Night/weekend call

– Patient’s not eligible for home health

• Cooperate, not compete– 9-1-1 collaboration

• Very different delivery models

• Align incentives

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• Other EMS-MIH Services– 9-1-1 Nurse Triage

– High Utilizer Programs

– Readmission prevention programs

– Ambulance transport alternative destinations

– NP/PA ambulances

• 260 programs nationwide– And growing

• 6 CMS HCIA Grants– ~$40 million from CMS to test model

NAEMT Survey

• 125 active EMS/MIH programs in U.S.

– 102 responses to this question…..

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• Fill gaps– Refer to enroll gap

– Night/weekend call

– Patient’s not eligible for home health

• Cooperate, not compete– 9-1-1 collaboration

• Very different delivery models

• Align incentives

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“Mobile Integrated Healthcare is an

innovative and patient-centered approach

to meeting the needs of patients and their

families. The model does require you to

“flip” your thinking about almost everything

– from roles for health care providers, to

what an EMT or paramedic might do to care

for a patient in their home, to how we will

get paid for care in the future.

The authors teach us how to flip our thinking

about using home visits to assess safety and

health. They encourage us to segment

patients and design new ways to relate to

and support these patients. And they urge

us to use all of the assets in a community to

get to better care. This is our shared

professional challenge, and it will take new

models, new relationships, and new skills.”

Maureen Bisognano

President and CEO

Institute for Healthcare Improvement

Texas:

What it means everywhere else: A place full of rodeos, boots,

horses, and cowboys.

What it means in Texas: Home, and the only place that matters.

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ems mobile integrated healthcare - new england …€“ integrated ems/home health inter ntion •...

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