Sean Kivlehan, MD, MPH, NREMT-P
September 2013
Source: CDC/Gindi, 2012
Source: CDC/Gindi, 2012
RETHINK EMS
At what point does "abuse of the system"
become failure of the "system" to adapt?
Things Change….
Re: Safety
Safer…(at least this thing had seat belts)
2009: Safest (so far)
Things Change….
Re: Communication
…a little easier….(although the other thing still makes a great step stool)
21st Century
Things Change….
Re: EDUCATION
1966: NAS/NRC
Accidental Death and Disability: The
Neglected Disease of Modern Society
1967: AAOS “Orange Book”
Emergency Care for the Sick & Injured
Things Change….
Re: THOUGHT PROCESS
OBJECTIVES
1. How We Got Here
2. Current Problems
3. How to Fix Them
How We Got Here
PART ONE
Young & Developing
1970 NREMT Formed
1973 Emergency Medical Services Systems Act
1975 AMA recognizes EMT-P
1977 National Standard Curriculum (NHTSA)
1984 NCSEMSTC reorganizes (and tries to
standardize) EMS Education
Still Evolving…
1990 Consensus Workshop on Emergency
Medical Services Training Programs
1993 National EMS Education and Practice
Blueprint
1994 EMT-Basic
1998 National Standard Curriculum for EMT-P
EMS Agenda for the Future, 1996
Emergency Medical Services (EMS) of the future will be
community-based health management that is fully integrated
with the overall health care system. It will have the ability to
identify and modify illness and injury risks,
provide acute illness and injury care and
follow-up, and contribute to treatment of
chronic conditions and community health
monitoring. This new entity will be developed from
redistribution of existing health care resources and will be
integrated with other health care providers and public health
and public safety agencies. It will improve community health
and result in a more appropriate use of acute health care
resources. EMS will remain the public's emergency medical
safety net.
~~NHTSA, NAEMSP, NASEMSD
2006 IOM Report: EMS at the Crossroads
“At its best, EMS is a crucial link to
survival in the chain of care, but within the
last several years, complex problems
… have emerged. Press coverage has
highlighted instances of slow EMS response
times, ambulance diversions, trauma center
closures, and ground and air medical
crashes.”
IOM Identified Concerns:
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The evolving role of EMS as an integral component
of the overall health care system.
EMS system planning, preparedness, and
coordination at the federal, state, and local levels.
EMS funding and infrastructure investments.
EMS workforce trends and professional education.
EMS research priorities and funding.
What Are The Current Problems?
PART TWO
What IS Public Health?
“The science and art of preventing disease,
prolonging life and promoting health through
the organized efforts and informed choices of
society, organizations, public and private,
communities and individuals."
“EMS will remain the public's emergency
medical safety net.”
• We see people in their home environment
• Often at their worst
• We can see the real needs they have
• We can address their issues at home
Leading Health Indictors
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Access to Health Services
Clinical Preventative Services
Environmental Quality
Injury & Violence
Maternal, Infant, & Child Health
Mental Health
Nutrition, Physical Activity, & Obesity
Oral Health
Reproductive and Sexual Health
Social Determinants
Substance Abuse
Tobacco
 Access to Health Services
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Adolescent Health
Arthritis, Osteoporosis and Chronic Back
Blood Disorders and Blood Safety
Cancer
Chronic Kidney Disease
Dementias, Including Alzheimer’s Disease
Diabetes
Disability and Health
Early and Middle Childhood
Educational and Community-Based
Programs
Environmental Health
Family Planning
Food Safety
Genomics
Global Health
Healthcare-Associated Infections
Health Communication and Health
Information Technology
Health-Related Quality of Life and WellBeing
Hearing and Other Sensory or
Communication Disorders
Heart Disease and Stroke
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HIV
Immunization and Infectious Disease
Injury and Violence Prevention
Lesbian, Gay, Bisexual, and Transgender
Health
Maternal, Infant, and Child Health
Medical Product Safety
Mental Health and Mental Disorders
Nutrition and Weight Status
Occupational Health
Older Adults
Oral Health
Physical Activity
Preparedness
Public Health Infrastructure
Respiratory Diseases
Sexually Transmitted Diseases
Sleep Health
Social Determinants of Health
Substance Abuse
Tobacco Use
Vision
Defining the Problem
• CDC needs report + Billings report reality
• People are going to the ER for things
• ER already needs to maintain 24/7 capability
and overhead.
• So does EMS
• Why not embrace the gap instead of fighting it
• So then, what are the barriers we face to fill
this gap?
Population Age
Chronic Disease
What are they?
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Heart Disease
Cancer
Asthma, COPD
Hypertension
Diabetes
Obesity
Addiction: Alcohol, Tobacco, Drugs
Leading Causes of Death (2010)
1. Heart disease: 597,689
2. Cancer: 574,743
3. Chronic lower respiratory diseases: 138,080
4. Stroke (cerebrovascular diseases): 129,476
5. Accidents (unintentional injuries): 120,859
6. Alzheimer's disease: 83,494
7. Diabetes: 69,071
8. Nephritis, nephrotic syndrome, and nephrosis: 50,476
9. Influenza and Pneumonia: 50,097
10. Intentional self-harm (suicide): 38,364
Depending on your location
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Language Diversity
Poverty Lines
Uninsured rates
Immigrant/Legal
Cultural
Preventable causes of death
• Behavioral: Smoking, Drinking, Obesity
• Unintentional Injury
• Opiate OD/prescription drugs
“14,800 overdose deaths in 2008, more than cocaine
and heroin combined.” (CDC)
How Do We Fix It?
PART THREE
Be a part of the solution
Failings vs Opportunities
Be a part of the solution
Failings are Opportunities
Be a part of the solution
Failings are Opportunities
“A new name for EMS”
Teachable Moments: Say it when you see it
1. What percent of patients have received a flu vaccine in the prior year?
2. What are the reasons why elderly patients don’t get a flu vaccine?
3. Offering flu vaccines to all elderly non-vaccinated patients
4. Do it, and then check it
Draft National EMS Education Standards
Competency: Public Health
Applies fundamental knowledge of principles of public
health and epidemiology including:
1. Public health emergencies
2. Health promotion
3. Illness & injury prevention
Expanded Roles of EMS Personnel
The American College of Emergency Physicians
(ACEP) acknowledges expanded scope of
practice programs are being developed in
response to community needs. ACEP recognizes
that EMS providers are likely to be used in the
workforce for these programs. With proper
design and medical oversight, potential benefits
may include improved access to health care in
underserved areas, improved patient care, and
reduced costs.
Data Collection
• Epidemiology
NEMSIS.org
“This effort will define EMS and prehospital care in a way never before
imagined, improving patient care and EMS
curriculum and defining a standard on with
to measure care.”
http://www.nemsis.org/theProject/thePartners/howToParticipate.html
Findings
• 136 million ER visits in 2009
• 15.8% took a 911 ambulance there
• 15% of Medicare patients could have been
safely treated elsewhere
• Would save $559.871 million a year
Why?
• “Doctor or clinic not open” (60%)
• “No where else to go” (40%)
• Anywhere from 11-61% of EMS transports
“unnecessary or avoidable”
• Incentivized to transport
• Overhead of 24/7 preparedness
Pre-Hospital & Post hospital
COMMUNITY PARAMEDICINE
Pre-Hospital #1
Transport patients with specified conditions not
needing emergency care to non-ED locations
• Mental health facility
• Sobering center
• Urgent care clinic
• Primary care physician’s office
Kizer, Community Paramedicine, 2013
Pre-Hospital #2
Refer or release at the scene
• Treat at home and follow up with their doctor
• Arrange for alternative care
• Currently we do this & then AMA (diabetics)
Kizer, Community Paramedicine, 2013
Pre-Hospital #3
Assist frequent users in accessing primary care
and other social services
• Centralized data identifies frequent users
• Work with a social services team to identify &
solve problems
– Police, Courts, Homeless Outreach, Social Work,
Housing
Kizer, Community Paramedicine, 2013
Post-Hospital #1
Support high-risk recent discharges from the
hospital
• Goal to reduce return visit or readmission
• Patients with poor family/social support
• CHF
• Diabetes
• Asthma
• Multiple chronic conditions
Kizer, Community Paramedicine, 2013
Post-Hospital #2
Support known chronically ill patients by making
periodic checks
• Provide education about how to proactively
manage the conditions
• Identify problems before they require the ED
Kizer, Community Paramedicine, 2013
Post-Hospital #3
Partner with community health workers and
primary care providers in underserved areas to
provide preventive care
• Flu Vaccines
• Blood Pressure monitoring
• Selected disease screening tests
• Education about illness, injury prevention, and
disease risk reduction
Kizer, Community Paramedicine, 2013
What about you?
EXAMPLES
SF Chronic Inebriates Program
• SFFD Homeless Outreach & Medical
Emergency (HOME) Team
• Small number of high system users
• SFGH spent $12.9 million a year, unpaid, for
225 frequent users
• Found users, connected them to resources
– Mental Health & Substance abuse dual care
– Boarding programs
San Diego
• Resource Access Program (RAP)
• People using multiple hospitals & calling from multiple
locations  EMS is the link
• 51 individuals in 31 months:
– EMS:
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encounters down 38%
charges down 32%
task time down 40%
mileage down 48%
– ED:
• encounters down 28%
• Charges down 12%
• Saved $314,000
MedStar – Fort Worth
• EMS Community Health Program (CHP)
• 21 patients with 800 ED visits in 12 months
– Over $1 million in EMS charges
• Initially helping access resources
• Expansion to CHF patients
– Referred by cardiac case managers
– Visit homes, holistic assessment, refer to PCP
• 23 patients: 44 admissions prevents (down 47%)
• Savings of $16,000 per patient
Minnesota
• CMS to reimburse:
– Health Assessment
– Immunizations
– Chronic Disease Monitoring
– Disease Education
– Lab Specimen collection
– Medication Compliance Checks
– Discharge follow up care
– Minor Medical Procedures
Triple Aim
• Better Care
• Better Patient Experience
• Reduced Cost
Paying For It
• Moving away from fee-for-service
• Towards pay-for-performance and bundled
care
• $13 million in CMS Grants to develop CP
programs
What are your ideas?
• This is just beginning, take a part in the
expansion of EMS’s role & help cement our
profession as a pillar of healthcare.
• Anyone can do a VF arrest – and MAYBE save
one life – Public Health saves populations.
Summary
EMS is the centerpiece of health & society, like
EM but better because it can penetrate
into the community
This isn’t a tweaking of EMS – this is redefining
EMS  Mobile Integrated Healthcare Practice
We cant waste this opportunity
Questions??
Comments??
More Info??
Email Me:
sean.kivlehan@gmail.com