By Kim Stanley, Chief Customer Officer, EMS Management & Consultants, and Brent Myers, MD, MPH, Director and Medical Director, Wake County Department of Emergency Medical Services
An estimated 240 million calls are made to 9-1-1 in the U.S. each year.1 While some of these calls are for genuine healthcare emergencies that require on-site treatment and transportation by emergency medical services (EMS) to a hospital’s emergency department (ED), many are for non-life-threatening healthcare problems.
But when EMS is called to the scene, patients in need of care — whether urgent or not — are almost always brought to the ED. There are a few main reasons why the ED has become the default site for the transportation of patients by EMS. The first is that in most communities, there is no infrastructure established for EMS to bring patients to other provider locations, such as physician’s office or mental health facility, that may serve as a more appropriate option than an ED.
The second reason concerns how EMS is classified at the federal level. EMS is an office of the National Highway Traffic Safety Administration, rather than the U.S. Department of Health and Human Services. EMS is therefore viewed as a transportation benefit. For EMS to receive federal reimbursement, transportation may only be to a hospital.
As a result of these factors, EMS is contributing to already busy EDs while opportunities are lost for EMS to help patients receive appropriate care in a timely, cost-effective fashion. But through partnerships established between hospitals and EMS, that can change.
In a shared-savings model, when the efforts of EMS contribute to reduction in ED visits and readmissions, the EMS agency receives a percentage of the hospital’s associated savings.
For example, some communities may be experiencing a mental health crisis, with mental health patients struggling to find appropriate inpatient care. When EMS is called in to assist a mental health patient and the patient is then transported to a hospital without inpatient psychiatric services, that patient will end up languishing in the ED.
But if a hospital works with EMS to develop a protocol by which a paramedic can clear many of these patients in the field and transport them directly to a mental health facility, this will not only reduce the number of ED visits but also ensure patients receive the care they need faster. In parts of North Carolina, this approach has reduced transports to EDs by about one-third with no patient safety issues reported.
In another example, EMS can provide services to reduce ED visits and readmissions that do not even require transportation of a patient. When patients discharged from a hospital are to receive home health visits, that first visit may not happen for a few days. But it is during the first day — and even first hours — after discharge when patients may find themselves confused about new prescriptions and a new medication regimen.
A hospital and EMS can establish a partnership where EMS agrees to visit a select group of patients, such as those discharged after congestive heart failure (CHF), pneumonia or myocardial infarction admission, within a few hours of discharge. While at patients’ homes, technicians or paramedics can reconcile medications, ensure prescriptions were filled correctly and check to make sure medication reminders are properly established.
By helping ensure patients take their medications properly, readmissions will decline and patient satisfaction will increase. Since federal reimbursement is becoming increasingly tied to satisfaction rates, when EMS can provide these services, hospitals will achieve savings and increased reimbursement.
In this model, an EMS agency provides services to a specific group of patients and is paid per patient, per month (or some other time period) for these services.
For example, an EMS agency may agree to provide care for a few hundred CHF patients. This would include home visits where paramedics provide medication reconciliation and other services intended to keep the patient well and out of the hospital. If EMS is effective in reducing this population’s CHF-associated readmissions, EMS could receive an additional incentive-based payment and see its contract to provide such services extended or expanded.
An EMS agency in Texas has begun to use this model in a limited but successful way. The agency has partnered with hospice groups and the hospital system to decrease admissions of patients on hospice care. The agency bills the local hospice groups based on a number of patients enrolled, not based on the number of visits.
There are other communities across the country where EMS is participating in a population-based cost savings model that have been very successful in increasing overall patient and family satisfaction and decreasing readmission rates.
Mobile Integrated Healthcare
If hospitals are interested in working with EMS and other agencies to reduce ED visits and readmissions, they will want to embrace the concept of mobile integrated healthcare (MIH). According to a vision statement on MIH (and community paramedicine) developed by the National Association of Emergency Medical Technicians and other national EMS and emergency physicians’ organizations, MIH can be defined as “the provision of healthcare using patient-centered, mobile resources in the out-of-hospital environment. It may include, but is not limited to, services such as providing telephone advice to 9-1-1 callers instead of resource dispatch; providing community paramedicine care, chronic disease management, preventive care or post-discharge follow-up visits; or transport or referral to a broad spectrum of appropriate care, not limited to hospital emergency departments.”2
To begin partnering in and rolling out these services, hospitals will want to sit down with agencies such as EMS and perform a community health needs assessment to determine the biggest problems facing their community’s emergency-based medicine. These may include, as previously discussed, mental health patients sitting in EDs for hours without receiving treatment or high readmission rates for CHF patients.
Once the assessment is completed, it is up to the hospital, working with these agencies, to determine who can provide the services needed to bring about improvement to the various stages of contact with patients that ultimately lead to the undesirable end result of ED visits or readmissions.
It is then a manner of determining how to make these partnerships and process improvements financially viable for the various participants. In addition to exploring the possibility of the two models discussed earlier, it may be worth bringing in representatives from your state’s Medicare and Medicaid department, as well as large insurance groups, to discuss other partnership opportunities.
When patients receive the appropriate care they need in a timely fashion and the support services that help them take better care of themselves, costs are reduced and outcomes are improved, which benefits everyone in the community.
- Nena.org,. ‘9-1-1 Statistics – National Emergency Number Association’. N.p., 2015. Web. 20 Feb. 2015.
- Naemt.org,. ‘Community Paramedicine &Amp; Mobile Integrated Healthcare’. N.p., 2015. Web. 24 Feb. 2015.