For years I wondered why despite being a confirmed urbanite, I love camping. Then I realized that camping gives me full permission to improvise—to make creative use of the limited materials I have to get the job done. Hence, shirt tails are fair game for wiping coffee grounds out of measuring spoons.
Similarly, I am inspired by people and groups that use the resources we have at our disposal in health care in creative new ways. Like the first explorers, these folks are testing approaches to provide care that are more effective than the status quo. Given the escalating health care costs, we need to be looking for ways to make the available financial resources work better for us. And, studies have shown that health care delivery includes a lot of wasted time, resources, and supplies, due in part to use of higher-priced services with no health benefits over less-expensive alternatives.
At a recent meeting on patient safety, I heard about a novel way of using a previously untapped resource—emergency medical technicians (EMTs), those courageous first responders to 911 calls. I followed up with Matt Zavadsky, MS-HSA, NREMT, who is the chief strategic integration officer at MedStar Mobile Healthcare, which provides emergency medical services (EMS) in the Fort Worth, Texas area, to learn more about it. Here’s what he told me.
For decades EMS units have been paid only to respond to emergency calls and transport people to the hospital. If they were to transport a person who needed less intense care to a lower acuity setting, like a walk in center or a clinic, they would not be paid—representing overuse of higher-priced services. In addition, EMTs, especially those based in fire departments, often spend a substantial portion of their shift waiting for emergency calls—representing underutilized human resources.
The idea to change the EMS system to better match patient needs with transport location emerged decades ago, but the fee-for-services payment system provided an incentive to bill for the most intense services rather than the services actually needed by the patient. In 2010, the passage of the Affordable Care Act allowed for payment based on value (delivering what the patient actually needs) instead of volume (more high acuity, hospital admissions and emergency department [ED] visits).
Zavadsky described three examples where EMS agencies are providing care navigation rather than only transporting people to the hospital. As he pointed out, these new models of care delivery are only sustainable where the EMS units are being reimbursed for the care of a population of patients rather than the number of ambulance transports completed. Today, large health insurance companies are signing capitated agreements (for example, an in-advance per-member-per-month fee) with EMS units to use their available resources to coordinate care and help covered patients navigate to the correct setting based on their needs.
9-1-1 Nurse triage
A 911 dispatcher uses a protocol to identify calls for non-urgent medical issues, which are transferred to a nurse who works in the 911 call center. The nurse queries the caller to determine the appropriate level of care and assists with transportation if needed. For example, if a parent calls about a child with fever, sore throat, and vomiting, and the pediatrician’s office is closed, the nurse can direct the parent to the after-hours pediatric clinic at the local children’s hospital and can provide arrange for paid transport to and from the clinic. The child avoids a long wait in the ED and has access to follow up care at the clinic if needed—and the insurance payer avoids the costly and unnecessary ambulance visit and ED cost. Plus, the EMTs and ambulance are freed up to serve people with high-acuity, emergency needs.
Hospital case managers provide EMS agencies with information about patients who are frequently seen in the emergency department or who frequently call 911. EMTs identify the unmet needs that are driving the high ED utilization and provide or facilitate in-home care, health coaching, and round-the-clock access to health care. For example, a young man who had developed an opioid addiction after a work-related back injury was visiting one of 10 EDs every day to obtain more prescription drugs. EMTs provided education and coaching, then worked with him to complete a pain management contract. Within 12 weeks he was opioid-free and remained so when interviewed several years later. A study of the program showed that ED visits and hospitalizations were significantly reduced—and participants’ reported quality of life improved.
Using a similar approach to that for the high-utilizer programs, at discharge hospitals refer to the EMS agency patients believed to be at risk for a preventable readmission. Paramedics visit these patients at home, review discharge instructions, provide health education, and ensure medication compliance and safety. They also ensure that patients are following up with their physicians and facilitate care in the home or at low-acuity settings, as needed.
According to Zavadsky, these programs can be very cost effective. His organization estimates that their nurse triage program saves $1,100 per patient caller (avoided expenditure for ambulance transport and ED visit), their high-utilizer program saves $17,000 per patient enrolled (avoided expenditure for ambulance transport, ED visits, and inpatient admissions), and their readmission management program saves $9,000 per patient enrolled, using average Medicare expenditure data as a comparison.
These models sounded intriguing but I wondered about quality measures—what mechanisms were in place to prevent withholding care at high-acuity settings when it is needed? Zavadsky sent me a list of the metrics that have been developed collaboratively with input from more than 50 stakeholder groups, including EMS associations, accrediting bodies, payer associations, and patient safety organizations. I was pleased to see the list included not only cost and utilization metrics, but also measures of adverse outcomes, unplanned acute care utilization, and patient and primary care provider satisfaction. Consistent with the overall move to value-based economic models, EMS agencies are reporting a subset of these metrics as part of the new models, including capitated agreements.
In addition to these existing programs, Zavadsky explained another way that EMTs—which he described as a “standing army of resources”—could work to improve care delivery. Just as firefighters conduct building inspections to reduce fire risks, EMTs could conduct home assessments for people at risk for injury in the home, malnutrition, or elder neglect. They could then contact health care providers or community services as indicated. EMTs could complete these assessments during existing downtime during their shifts. In addition, during 911 calls for medical services firefighters could use a simple checklist to identify homes with safety concerns.
These models of care delivery are exciting because they use existing resources in a novel way and represent a triple win, with benefits for patients, care providers, and payers. Don’t you love it when a creative idea works?