Πέμπτη, 28 Μαρτίου 2019 09:48

Using Community Paramedicine, mHealth for Care Coordination at Home

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Community paramedicine programs give health systems an mHealth platform upon which to improve care management and coordination at home for high-need patients.

Community paramedicine programs offer hospitals and health systems an opportunity to leverage mHealth to reduce emergency department costs and improve care management for patients with complex chronic diseases.

Mobile Integrated Health Community Paramedic (MIH-CP) programs are often rooted in partnerships with local EMS and ambulance companies. They deploy specially trained paramedics to the homes of selected residents, often targeting frequent users of the 911 system.

These programs have two primary goals.

The first is to reduce unnecessary ED transports by visiting “frequent flyers” . This, in turn, reduces the strain on crowded EDs and, in the long run, reduces the number of non-emergency 911 calls.

Secondly, community paramedics aim to help those with complex chronic conditions improve their health and wellness at home, thereby improving care coordination and  the relationship between patient and primary care doctor.

“Community paramedicine is not a new field, but it is a growing one in the era of innovative care delivery models that emphasize integration across disciplines, a comprehensive approach to care coordination, and a commitment to reducing health disparities,” Carol Backstrom and Jennifer Ryan, both of Harbage Consulting, wrote in a 2017 Health Affairs article.

Developing an impactful, cost-effective CP program requires communities and healthcare providers to collaborate on implementing technologies and care strategies that harness all the resources at their disposal.

BUILDING UPON THE MIH-CP PROGRAM FRAMEWORK

The MIH-CP movement got its start in 1996, when the National Association of Emergency Medical Technicians (NAEMT) unveiled an EMS Agenda for the Future that shifted some of the focus to community health services. The NAEMT now offers a mission statement for MIH-CP programs.

“Recent changes in the healthcare finance system have created an unprecedented opportunity for EMS to evolve from a transportation service to a fully integrated component of our nation’s healthcare system,” the document states.

“Aligned financial incentives now focus stakeholder awareness on the value of EMS in providing either “patient navigation” throughout the healthcare system, efficiently and effectively directing each patient to the right care, in the right setting at the right time, or providing primary care in medically underserved areas.”

According to this mission statement, an effective MIH-CP program should be:

  • Fully integrated – acts as a vital component of the existing healthcare system, with efficient bidirectional sharing of patient health information.
  • Goal directed – is predicated on meeting a defined need of a specific patient population in a local community articulated by local stakeholders and supported by formal community health needs assessments (HNAs).
  • Patient-centered – incorporates a holistic approach focused on the improvement of patient outcomes.
  • Collaborative – works together with existing healthcare systems or resources and fills resource gaps within the local community.
  • Consistent with the Triple Aim - improves the patient experience of care, improves the health of populations; and reduces the per capita cost of healthcare.
  • Data-driven – leverages data to develop evidence-based performance measures, research and benchmarking opportunities.
  • Physician-led – is overseen by engaged physicians and other practitioners, as well as the patient’s primary care network/patient-centered medical home, using telemedicine technology when appropriate and feasible.
  • Team-based – integrates multiple providers, both clinical and non-clinical, in meeting the holistic needs of patients who are either enrolled in or referred to MIH-CP programs.
  • Educationally appropriate – includes more specialized education of MIH-CP practitioners, with the approval of regulators or local stakeholders.
  • Financially sustainable – includes proactive discussion and financial planning with federal payers, health systems, managed care organizations,, legislatures, ACOs, and other stakeholders to establish MIH-CP programs and component services as an element of Triple Aim approach.
  • Legally compliant – meets all legal criteria through strong, legislated enablement of MIH-CP component services and programs at the federal, state and local levels

In a January 2019 blog  post on Health Affairs, Caitlin Thomas-Henkel, a senior program officer at the Center for HealthCare Strategies (CHCS), and Sandi Groenewold, a family physician with ThedaCare, note that such a CP program can put specially trained paramedics right into the home, “where they may discover unexpected barriers and underlying factors that affect health outcomes.”

“A community paramedic can investigate these issues firsthand and seek ways to solve them through patient education (such as needing to take food with certain medications, developing reminders for medication schedules, or special packaging), connecting the patient with community resources, or both,” they wrote. “This approach is a paradigm shift that differs from the traditional one-way model of medication prescribing and dispensing to a patient-centered approach.”

In this model, Thomas-Henkel and Groenewold suggest using a telehealth platform to keep the primary care provider, pharmacist, specialists and other care team members in the loop, letting them know when home visits are conducted, allowing them to communicate with the patient and even looping them in for a virtual visit when needed.

CHOOSING THE RIGHT MHEALTH SERVICE

Prior to launching an MIH-CP program, a health system should first survey its goals and target population to make sure it is choosing the proper mHealth service for its needs.

Matt Zavadsky, MS-HSA, EMT, Chief Strategic Integration Officer for MedStar Mobile Healthcare, which provides EMS services for Fort Worth and 14 other cities in North Texas, notes that the overarching Mobile Integrated Healthcare platform commonly refers to five different types of mobile health services:

  1. Community paramedicine, in which specially trained paramedics are dispatched to the homes of a targeted population, such as residents with complex chronic conditions or frequent users of 911.
  2. 911 nurse triage, in which nurses stationed in 911 call centers screen incoming calls to determine how best to help the caller.
  3. Alternate destinations, in which the EMS service dispatched to a 911 call is able to triage the caller and determine what healthcare service is best needed.
  4. Alternate response, in which different types of providers are dispatched based on the healthcare emergency.
  5. High-utilizer programs, which provide home-based care for residents who often require healthcare services.

“You have to know what you want to do before you get into it,” Zavadsky, who’s also president of the NAEMT, told mHealthIntelligence.com.  “And be prepared to fail before you succeed.”

Zavadsky advises providers to conduct a gap analysis, which will help them to identify the pain points that affect care coordination. Then, a health system needs to create a program that not only improves care coordination but can also appeal to the local EMS providers.

“Remember, EMS gets paid to transport,” he says. “You are going to ask them to commit to doing something different with patients.”

Some health systems focus their attention on the 911 call center, either by adding specially trained staff to screen incoming calls or setting up a protocol to send different types of providers to the scene, such as an ambulance, doctor or community health worker.

One such program – perhaps the national model for this particular service – is Project ETHAN (Emergency TeleHealth And Navigation) in Houston. Launched in 2016, the program links the city’s fire and rescue first-responders with a call center manned by physicians from 8:00 AM to 10:00 PM on  weekdays and 10:00 AM to 6:00 PM on weekends. When dispatched on a 911 call, an EMT can use a tablet to open a video chat with an emergency physician, who can speak to the patient, access medical records and advise whether the patient needs to be transported.

“There’s really a lot of good that has come out of this,” Dr. Michael Gonzalez, the program’s director and a professor of emergency medicine at nearby Baylor University’s College of Medicine, told mHealthIntelligence.com in a 2016 interview. “The ideal outcome is that the patient avoids the ER transport and winds up with their primary care provider. That benefits everybody involved.”

While that program works in Houston, Zavadsky says many health systems are leaning toward MIH-CP programs because they tend to be less resource-intensive and can fit into the health system’s population health workflows.

REGULATIONS AND GUIDELINES FOR MIH-CP PROGRAMS

According to a 2017 analysis of state laws, 41 states define a scope of practice within their EMS laws that takes into account some form of community paramedicine.  Twenty of those state have a clearly defined mechanism for expanding CPs, including seven states that allow EMS providers to transport patients to a location different than the ED.  

Conversely, some states have laws on the books that restrict EMS providers to providing emergency medical and first response services.

The first state to set up a regulatory framework for community paramedicine was Minnesota. In 2011, Governor Mark Dayton signed the Community Paramedic Bill, creating a certification program for community paramedics. The next year, the state legislature enabled reimbursement for CP programs through Medicaid.

In 2017, Wisconsin lawmakers made national headlines with the unanimous approval of Act 66, which sets clear guidelines for training community paramedics (CPs) and community emergency medical technicians (CEMTs). Among the requirements, CPs and CEMTs must have at least two years experience as a licensed and qualified EMT or paramedic and must successfully complete a training program.

Under the rules, a CP or CEMT may perform services:

  • for which he/ she is trained under the training program;
  • that don’t duplicate services already provided to the patient; and
  • are either approved by the healthcare provider with which he/she is employed or contracted, or that are included in the patient care protocol submitted by the community emergency medical service provider.

In addition, community emergency medical services (CEMS) providers must be licensed by the Department of Health and Human Services at any emergency medical services level; they must establish and submit to DHS patient care protocols to be used by a CP or CEMT; and they must provide a roster of active CPs or CEMTs.

Colleges and universities have also been developing courses in community paramedicine. The national Community Paramedic organization has developed a standard curriculum that covers topics like the social determinants of health, public health and tailored learning about chronic diseases, community assessments and strategies for managing care and disease prevention.

FUNDING MIH-CP PROGRAMS

Funding and reimbursement are still major barriers to launching a community paramedicine program. Many such programs are launched through grants from charitable foundations or the National Institutes of Health. Some are reimbursed through state Medicaid, while others are launched in a collaboration with payers such as Anthem Blue Cross Blue Shield, which covers community paramedicine services in 14 states.

Federal recognition has been slow, but took an important step forward in early 2019 with the unveiling of the Emergency Triage, Treat and Transport (ET3) model by the Center for Medicare and Medicaid Innovation.

Under a five-year test program scheduled to begin in 2020, Medicare will begin reimbursing for some programs that either dispatch specially trained healthcare providers to the scene of a 911 call or enable transport to an alternative care location, such as an urgent care clinic or primary care provider’s office, that would offer more appropriate care than an ED.

“This model will create a new set of incentives for emergency transport and care, ensuring patients get convenient, appropriate treatment in whatever setting makes sense for them,” HHS Secretary Alex Azar said in a press release.

“Today’s announcement shows that we can radically rethink the incentives around care delivery even in one of the trickiest parts of our system. A value-based healthcare system will help deliver each patient the right care, at the right price, in the right setting, from the right provider.”

Under the Affordable Care Act Hospital Readmissions Reduction Program, hospitals that exceed more unplanned readmissions of Medicare beneficiaries than expected for specified conditions are penalized by reductions, up to 3 percent, of the Medicare reimbursements to which they would otherwise be entitled.

“Hospitals can be financially rewarded by contracting with an EMS agency that offers a community paramedicine program designed to provide patient care that will reduce hospital readmissions,” says Kenneth Brody, an attorney with Page, Wolfberg & Wirth, LLC, noting that the cost of a CP program is likely significantly less than potential penalties under the CMS readmissions program.

“Having EMS providers conduct in-home visits to patients participating in a community paramedicine program, without using an ambulance to do so, is far less expensive than having EMS providers respond to a preventable emergency dispatch and then transport the patient by ambulance to a hospital emergency department,” Brody says.

“If government and commercial insurers are convinced that community paramedicine programs will reduce ambulance transports and hospital care for their beneficiaries, while costing less than they would otherwise be paying for services they cover, they have an incentive to revise their reimbursement policies to cover community paramedicine services.

PLANNING FOR SUSTAINABILITY AND SCALABILITY

Brody also urges new MIH-CP providers to collaborate not only with local fire and rescue departments, but also with community leaders and other healthcare providers.

“Seek to avoid, or at least minimize, opposition to community paramedicine programs from other health care providers such as nurses and home health care agencies,” he says. “They may see these programs as infringing upon their turf. Meet with them and their associations to identify needs in the healthcare system that they are not addressing and discuss how community paramedicine programs can help to address those needs.”

“Explain how community paramedicine programs are not competing with them and that by filling gaps in access to care community paramedicine programs can be a source of referrals to other health care services. Also, meet with patient advocacy groups to explain the benefits of community paramedicine programs and seek to gain their support.”

One program showing success is in Milwaukee, where the city’s fire department launched a program in 2015 after a review of more than 60,000 annual 911 calls found that 7 percent, or 4288 calls, came from the same 100 people.

The 34 paramedics involved in the program receive 200 hours of managed care training from the University of Wisconsin-Milwaukee College of Nursing, in collaboration with the Medical College of Wisconsin. The program was aided by state legislation passed in 2017 that gave paramedics more leeway to provide services in non-emergency situations.

With the program in place, phone calls from those targeted patients dropped 26 percent from October to December 2015, fire department officials said. In 2016, those calls were reduced by 56 percent, and in 2017 the call volume dropped 62 percent.

According to the NAEMT, some 260 EMS programs across the country were using some sort of community paramedicine program by mid-2017, up from just 100 programs in 2014.

As communities search for more cost-conscious and clinically effective ways to manage care coordination and reduce stress on their emergency departments, community paramedic programs are becoming a viable option.

While organizations will still need to seek out funding and work closely with local lawmakers and community partners to develop CP programs, the concept of leveraging first responders for a more preventive approach to care is rapidly gaining traction across the nation.

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