Role of Community Paramedicine in Enhancing Service Integration and Population Health

1. Role of Community Paramedicine in Enhancing Service Integration and Population Health John Gale, MS NOSORH Region C Meeting Lansing, MI August 13, 2015

2. Contact Information John Gale, M.S., Research Associate Maine Rural Health Research Center –U. of Southern Maine 207-228-8246 jgale@usm.maine.edu For more information on the Evaluation of the Maine Community Paramedicine Pilot and FMT CP Briefing Paper, contact: Karen Pearson, MLIS, MA, Project Director 207-780-4553 karenp@usm.maine.edu

3. Overview • Realities of our current health care and emergency care systems • Overview of growth in community paramedicine (CP) programs • Opportunities to enhance system integration and population health • Challenges and barriers • Financing, reimbursement, and data issues • Examples: Maine, California, and South Carolina

4. Realities of Health Care • Health care organizations are working towards greater value, quality, and integration • Systems of care and policymakers are increasingly recognizing the value of integration and population health • Payment demonstrations are encouraging reform • Wide spread changes to the payment system will take time • Secretary Burwell’s delivery system reform initiative seeks to accelerate the pace • No systems or communities have all the resources needed – particularly rural systems of care/communities

5. Emergency Department Usage • 911 and emergency departments are often the de facto safety net for non-emergent services in rural communities • 14-27% all ED visits are for non-urgent care and could take place in a different setting (2010 Rand study) • Potential cost savings of $4.4 billion annually • 36% increase in ED visits from 2006 • 4.5-8% of ED patients = 21-28% of ED visits (Annals of Emergency Medicine, 2010) • Causes: Poor access to primary care, increasing numbers of people with chronic illness, lack of Insurance/poor insurance coverage, homelessness

6. EMS System Redesign • Balanced triage • Patient-centered • Integrated with other components of the healthcare system • Stakeholder engaged • Payer-aligned • Leverages HIT

7. Current EMS Reimbursement Systems • Fee for Service – Medicare Ambulance Fee Schedule, Medicaid, third party payers, self pay • Payment only for transport • ED only destination following 911 response

8. The “Future” of EMS Reimbursement • Payment for assessment and care as well as transport • Payment for alternative destinations • Payment for new roles and types of healthcare personnel • Recognition for investment in HIT • Workforce development - expanded role for CPs, engagement of other personnel (e.g., RNs – nurse navigators) • Early advanced assessment in the field • Payment for system performance

9. CP/MIHP Logic Model (by Eric Beck, et al)

10. Data – Needed to Document Performance and Value • Center for Medicare and Medicaid Improvement’s Big 4 • Total cost of care • Hospital ED visits • All cause hospital admissions • Unplanned 30 day re-admissions • CP/Mobile Integrated Health Measures • Ambulance transport savings • Hospital ED visit savings • All cause hospital admissions savings • Total expenditure savings

11. Data – Needed to Document Performance and Value (cont’d) • Other important measures to monitor CP/MIH • Specialized training and education • Primary care utilization • Medication inventory • Unplanned acute care utilization • Patient satisfaction • Patient quality of life • Ambulance transports • Provider (EMS) satisfaction • Partner satisfaction • Primary care provider satisfaction

12. Potential Partners • Collaboration, not competition is key • Augment, extend, and coordinate services – not replace • Health plans • ACOs • Hospitals • Hospice Organizations • Home health agencies • Physician practices • Public health • Geriatric programs

13. What Gaps Can CPs Fill? • Integrate EMS resources to better address unmet health care and public health needs as a system of care • “ Treat and release” – provide on the spot care for minor illnesses and injuries – freeing ED resources • Patient navigation and transport • Re-direct 911 patients to alternative, appropriate settings • Reduce frequent ED fliers by working with local providers • Preventive care – screening, education, and immunizations • Post-acute care –reduce unnecessary readmissions by following up with discharged patients • Chronic illness management

14. Funding Community Paramedicine Programs • Reimbursement issues are the most challenging for the “non-transport” services provided by CPs • Funding for the CPs most often is provided by the ambulance company and sponsoring organization • Some hospitals provide funding for CPs • Grants: CMS Innovation Grant (WA-rural hospital model, NV-urban model), California Health Foundation • Commercial insurer: PA (urban model) • State Office for Aging: NY

15. Maine Pilot Requirements • Sites were required to apply for participation in the pilot • Proposals were required to: • Identify other health care partners within the community • Work with partners to identify unmet community healthcare needs • Identify PCP/medical director and EM medical director • Provide a training, quality improvement, and data collection plan • Applicants committed their own resources to demonstrate value. Some sought local funding • Evaluation funded by Maine Emergency Medical Services and being conducted by Maine Rural Health Research Center – Karen Pearson, MLIS, MA, Project Director

16. Maine CP Pilot Sites • Calais Fire Department • Area served by a CAH with a shortage of PCPs. Patients w/o a PCP are assigned one before first CP visit • In-home management of patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and hypertension • Services include a physical assessment, vital sign monitoring, medication reconciliation, blood draws, and 12 Lead EKG • Castine Fire Department First Responders • Small volunteer fire department working closely with a local physician • CPs visit 6-10 patients as directed physician. Primarily performs basic patient assessment (vital signs, etc.) and overall safety/wellness check • Recorded 100 visits to residents homes (2013-2914 Annual Report)

17. Maine CP Pilot Sites (Report to Legislature 1/28/15) • C.A. Dean Ambulance, Greenville • A CAH operated ambulance service covering an extremely rural/ wilderness part of Maine. • Limited primary care and home health provider supply • In home management of chronic congestive heart failure, chronic obstructive pulmonary disease, and diabetes patients • Greater Kennebec County CP Pilot Project • Delta Ambulance (Augusta & Waterville) & Winthrop Ambulance. This project also .includes active participation and coordination between the Belgrade Regional Health Center and Winthrop Family Medicine. • Due to overlap in clinic catchment areas, PCPs together to assure efficient CP assignment based on patient location and available resources

18. Maine CP Pilot Sites (Report to Legislature 1/28/15) • Lincoln County Healthcare, Central Lincoln County Ambulance, Boothbay Regional Ambulance, Waldoboro EMS • Development on this project began in conjunction with the closing of St. Andrew's Regional Hospital, (a CAH) in Boothbay • Lincoln County Healthcare, Miles Memorial Hospital works with several primary care providers to provide post hospital discharge follow-up and at home episodic health care throughout several communities. • Incorporating use of video technology (iPads on a secure network) to communicate with primary care and/ or ED providers

19. Maine CP Pilot Sites (Report to Legislature 1/28/15) • Mayo Regional Hospital Ambulance, Dover-Foxcroft • CAH-B based ambulance service covering rural Piscataquis County • Initially, patients primarily identified by hospital discharge planner or ED. Other primary care practices affiliated with Mayo Hospital will be invited to participate as the program evolves • North East Mobile Health, Rockport • Largest paramedic service in Maine • Works primarily with Penobscot Bay Medical Center and Maine Medical Center to follow-up with fall patients • During 2015, this may be expanded to other areas and .include follow-up care with trauma patients for wound care

20. Maine CP Pilot Sites (Report to Legislature 1/28/15) • Northstar EMS, Franklin Memorial Hospital, Farmington • Northstar has 5 base locations throughout Franklin County • Works with PCPs to identify patients who may benefit from CP care (e.g., newly discharged, recent surgery, multiple chronic conditions, or safety concerns in the home) • “House Call” program to educate and re-engage patients, monitor their condition, and provide appropriate treatment • St. George Ambulance, Port Clyde • Increased staffing to work with Kno-Wal-Lin Home Care and Hospice, Penobscot Bay Hospital, area PCPs to care for patients in Port Clyde • Collaboration between community health and CP programs • Provides help with post-surgical wound care, medication compliance, post-discharge care, and home assessments

21. Maine CP Pilot Sites (Report to Legislature 1/28/15) • Searsport Ambulance • Works with local primary care providers and Waldo General Hospital (a CAH) to identify patients meeting the criteria for a CP visit • Ambulance service actively works with other organizations to promote public health programs such as dental clinics and blood drives. • United Ambulance, Lewiston. • 2 part time staff dedicated to working with local primary care practices and providing home visits for primarily fall and diabetic patients • Anticipates seeing an expanded variety of patients • Crown Ambulance, Aroostook Medical Center, Presque Isle • Part of the hospital's ACO plan - one of the first to include EMS

22. Twelve Site California CP Pilot • Driven by UC Davis Institute for Population Health 2013 report funded by the California Healthcare Foundation • November 2014, the California Emergency Medical Services Authority received approval to pilot CP in 12 sites • Implementation time line • January 2015-June 2015 training of providers by UCLA Center for Pre-Hospital Care • June 2015 – August 2015 implementation of sites • Evaluation by Phillip R. Lee Institute for Health Policy Studies and Center for Health Professions. The UC San Francisco with final report due in June 2017

23. California Pilot

24. California Pilot

25. Abbeville County CP Program • Rural South Carolina community with a CAH • CP program funded by Duke Endowment – includes a Care Transition Nurse • Program goals • enroll patients in CP program • decrease readmission rate • decrease non-emergent ED visits • identify community resources and partners

26. SC Healthy Outcomes Program • State implemented the Healthy Outcomes Program in 2013 • Supports hospitals to develop systems to coordinate care for chronically ill, uninsured, high utilizers of ED services • Potential funding for CAH/community providers - $1.25 mil • HOP enabled increased collaboration between CAH, CP program, local free clinic • Target enroll 50 uninsured patients / actual 52 • Contacted patients and scheduled home visits to enroll patients • Assessments of individuals – social determinants, Global Appraisal of Individual Need (GAIN), Patient Activation Measure (PAM) • Care transition nurse rides along with CPs

27. Key Strategies to Maximize Value of CP • Engage in local community health needs assessments – 501(c)3 hospitals and public health are increasingly engaged • Focus on integrating with overall systems of care • Develop data capacity to monitor and document quality, costs savings, system performance, and value • Identify/report service and system performance measures • Be sensitive to competitive issues • Collaborate – share data and resources • Understand reimbursement incentives for all stakeholders • Interact with system of care stakeholders regularly