Paramedics de­ployed as care nav­i­ga­tors

Modern Healthcare - - BEST PRACTICES - By Steven Ross John­son

For­mer para­medic Matt Za­davsky long be­lieved that there was a broader role for his pro­fes­sion be­yond sim­ply re­spond­ing to emer­gen­cies.

In line with a 1996 Na­tional High­way Traf­fic Safety Ad­min­is­tra­tion re­port, he en­vi­sioned a sys­tem in which paramedics func­tioned as nav­i­ga­tors, steer­ing pa­tients to the most ap­pro­pri­ate care set­ting to re­duce use of hos­pi­tal emer­gency de­part­ments.

But he en­coun­tered re­sis­tance. “Every­where I went, peo­ple said, ‘Why would we want to pre­vent 911 calls, ER vis­its and (hos­pi­tal) ad­mis­sions? That’s how we get paid,’ ” re­called Za­davsky, now pub­lic af­fairs di­rec­tor for the Fort Worth, Texas-based Area Met­ro­pol­i­tan Am­bu­lance Author­ity, a pub­lic agency also known as MedS­tar Mo­bile Health­care.

That at­ti­tude about ED treat­ment and hos­pi­tal ad­mis­sions was chang­ing by 2009, as health sys­tems fo­cused on avoid­ing in­ap­pro­pri­ate, high-cost care. That year, Za­davsky and his agency de­cided to see whether the idea, known as com­mu­nity paramedicine, could be a vi­able busi­ness model. His agency is the ex­clu­sive emer­gency med­i­cal ser­vices provider for the Fort Worth area, serv­ing more than 900,000 res­i­dents.

MedS­tar be­gan by iden­ti­fy­ing the most-fre­quent users of am­bu­lance ser­vices—area res­i­dents who had called 911 at least 15 times in the pre­vi­ous 90 days. An anal­y­sis of 2008 data found that 21 pa­tients ac­counted for 800 calls that year, with many calls made for non-emer­gency sit­u­a­tions.

The pi­lot project en­rolled nine of the 21 fre­quent call­ers. For 60 days, two paramedics were as­signed to pro­vide pri­mary-care ser­vices to those pa­tients. The re­sult was a 77% drop in 911 calls by the end of the pi­lot, and an 80% re­duc­tion in hos­pi­tal read­mis­sions. Those re­sults prompted MedS­tar to es­tab­lish a full-scale di­ver­sion model that it calls its mo­bile health­care pro­gram.

Gary Win­grove, di­rec­tor of strate­gic af­fairs for Mayo Clinic Med­i­cal Trans­port in Min­nesota, said more health sys­tems na­tion­wide are in­ter­ested in the com­mu­nity paramedicine model be­cause they are in­creas­ingly be­ing paid to keep pa­tients healthy and out of the hos­pi­tal and the ED. “They see that as an op­por­tu­nity where the com­mu­nity para­medic can show value to that sys­tem,” Win­grove said. “The com­mu­nity para­medic be­comes a part of their work­force and part of that bun­dled pay­ment they get.”

Un­der the MedS­tar pro­gram, reg­is­tered nurses at MedS­tar’s call cen­ter eval­u­ate 911 call­ers and de­cide which ones might be ap­pro­pri­ate for the mo­bile health­care pro­gram. Paramedics go see el­i­gi­ble pa­tients, as­sess­ing their ap­pro­pri­ate­ness for the pro­gram and their will­ing­ness to par­tic­i­pate.

En­rollees re­ceive a med­i­cal as­sess­ment and a care plan that in­cludes fol­low-up home vis­its and tele­phone calls. The paramedics also help pa­tients with other needs, such as trans­porta­tion for doc­tors’ of­fice vis­its or sign­ing up for health in­sur­ance and other ben­e­fit pro­grams.

The pro­gram re­quires paramedics to re­ceive 80 hours of class­room train­ing and 80 hours of field train­ing fo­cus­ing on com­mu­ni­ca­tion skills, care nav­i­ga­tion and knowl­edge of com­mu­nity re­sources to as­sist pa­tients.

An ini­tial chal­lenge for the MedS­tar pro­gram was fig­ur­ing out how to get paid, be­cause in­sur­ers did not pay for home vis­its or care co­or­di­na­tion. So the agency be­gan it as a self-funded project to prove the pro­gram worked.

Even­tu­ally, grow­ing pres­sure to re­duce costs sparked provider in­ter­est in MedS­tar’s model, which led to agency con­tracts with sev­eral hos­pi­tals and hospice providers. Re­cently, Meds­tar signed a con­tract with Cigna-Health­spring, a large Med­i­caid man­aged-care plan in the Fort Worth area, to serve its mem­bers.

“Once we started the first pro­gram, lit­er­ally five other pro­grams, or­ga­ni­za­tions and part­ners came to us and asked us to help them,” Za­davsky said. “The to­tal eco­nomic en­vi­ron­ment in health­care has been turned up­side down.”

Since 2009, the pro­gram has re­duced hos­pi­tal ED trans­ports by 82% for pa­tients iden­ti­fied as fre­quent EMS users, saving nearly $8 mil­lion in health­care costs, MedS­tar said.

In 2010, the pro­gram ex­panded to in­clude con­ges­tive heart-fail­ure pa­tients at risk of ad­mis­sion to the ED or the hos­pi­tal.

Za­davsky said com­mu­nity paramedicine also could be ex­panded to serve pa­tients with se­vere men­tal ill­ness who fre­quently use the ED, and of­ten have to be re­main there for hours or days while staff search for more ap­pro­pri­ate treat­ment set­tings.

Staffers from more than 140 EMS pro­grams around the coun­try have vis­ited MedS­tar’s pro­gram to learn how to start their own mo­bile health­care ef­fort, Za­davsky said.

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