Fire ServiceBased EMS
Adapting to the Changing Face of
Healthcare…
A Paradigm Shift for the Fire
Service
What We Know
The Affordable Care Act is accomplishing
the following:

Reducing the number of uninsured in
America

Enhancing the level and quality of
primary care providers to citizens

Providing expanded benefits to covered
individuals
What We Know

Not enough Primary Care Providers

The Emergency Department fills voids but is
expensive

Accountable Care Organizations (ACOs)
Our New Environment:

• ACA tipped the 1st domino

New partnerships/New opportunities

Aligned incentives & risk sharing

Bundled payments based on episode of care

Payment based on OUTCOMES
Our New Environment: Example

There are 4.6 million Medicare beneficiaries with
CHF
 14%
of beneficiaries have CHF
 43%
of Medicare spending on CHF

One CHF admission cost CMS $17,500

30‐day readmission rate for CHF = 24.7%

Patients do not see their doc between discharge
and readmit

= $12 billion CMS expenditures for Potentially
Preventable Readmissions
Mobile Integrated
Health- Community
Paramedic
National Perspective
Mobile Integrated Health

Focus on patient-centered navigation and transparent
population specific care

Operates through population-based needs
assessments

Leverage multiple strategic partnerships under
physician medical oversight

Multidisciplinary and inter-professional teams
Community Paramedic Defined

Licensed/ Certified Paramedic with Additional
Training
 Physiology,
disease processes, injury and illness
prevention, and medical system navigation

Population
 Public
health services to elderly, underserved, and
chronic condition- primary care and social services

Health Care
 health
assessment, chronic disease monitoring,
education, medical care and prescription regime
compliance, immunizations and vaccinations,
laboratory specimen collection, hospital discharge
follow-up care, and minor medical procedures
MIH-CP Defined

Program can provide means to free emergency
response units when no actual emergency exist… but
still meet needs of patient
 walk-in
clinics, mental health triage, social detox
facilities, shelters and homeless services, and in-home
assistance

Schedule in-home evaluation of high-risk patients
following hospital discharge
 EKG,
blood glucose, pulse oximetry, venous lactate,
end-tidal carbon dioxide, along with the standard vital
signs, and optional blood draws
Public Education and
Outreach

Community CPR and Medical ALS Training
Program

Accessing the Medical Care System

Wellness Programs

Targeted Prevention Strategies
 Fall Prevention Program
 CHF, COPD, HBP, Diabetes etc.
 Readmissions
Specific Opportunities

Transportation to alternate (non-emergent) facilities

Post-discharge monitoring

Disease management monitoring and assessment

At home services (augment traditional in home care)

Patient and community education

Public health support (government programs)

Participation in demonstration projects funded by the
Center for Medicare and Medicaid Innovation
Competition

We are not alone

Because of the savings and the potential
to increase patient service areas
everyone should be thinking about this

The bad news is we may be behind…The
great news is we are not alone there
either.

http://youtu.be/ZBEAvkzBKVE
AMR- Las Vegas

“Making Las Vegas a Better Place to Live”

http://www.jrn.com/ktnv/news/better-lv/AMR-making-sure-9-11-calls-are-real-emergencies-225185752.html

February 2014, CVS announces it will stop
selling tobacco products in October

Estimated Annual Loss = $2 Billion in Sales

Moving the Company’s focus to Healthcare
800 minute clinics

employs 26,000 pharmacists and nursepractitioners
Other Players

Insurance Companies

Assisted Living Companies

Home Healthcare
What Can Fire Service Leaders Do?

Operational prioritization
 How
will core EMS responsibilities be balanced
with new services being explored?

Market needs assessment
 Community
 Services
health care needs
currently being provided through
other competition (e.g. other providers
positioned to offer same)
What Can Fire Service
Leaders Do?


Look for Legal and political obstacles

Are there state statutes that prohibit EMTs and paramedics from
providing certain types of care?

Do municipalities have restrictions on how publically funded staff
and facilities can be used?
Operational readiness

What expanded services can be provided based on available
expertise, or without significant additional effort?

What is the staff capacity for service expansion?

What systems (e.g., billing, medical records receipt and
transmission) need to be put in place?
“In order to comply with current Virginia law, EMS
agencies interested in providing MIH/CP programs may
require licensure as home care organizations by the
Virginia Department of Health Office of Licensure and
certification”
-April, 2014
“Ohio law allows EMS providers to perform only
emergency medical services.”
“EMS providers should be aware that immunity from civil
liability applies only if they are administering
“emergency” medical services.”
- April 14, 2014

In February 2014, EMSA submitted a complete
application to the Office of Statewide Health
Planning and Development (OSHPD) through the
Health Workforce Pilot Projects (HWPP)
program

It was not approved and is under review by
OSHPD as HWPP application #173
What Can Fire Service Leaders Do?

Financial modeling
 Incremental start-up costs
 On-going operating costs
 Demand (expected utilization)
 Preliminary reimbursement model
 Profit/loss position

Explore possible partnerships
 (e.g., hospitals, delivery system, public health,
etc.)
IF… Common Ground Found…

Assess need for services other than
emergency treatment and transportation
 May
include post-discharge patient
consultation and care management services
for patients with chronic conditions.

The terms of the initial agreement will be
important!
Considering Agreements

EMS provider organizations explore partnerships

Engage professional support to help guide the process.

Assess the areas mentioned including services currently
provided
 Partners
could range from well-organized physician groups
to hospitals and health care delivery systems

Have an initial conversation with executives of the
organizations
 introduce
the potential of a partnership,
 understand
 give
the organization’s strategy
an example of the value the fire department can
provide.
If Common Ground Found…

Determine whether there is the potential for improved quality
and lower cost using a fire department model versus the current
options

Assess the impact of possible “public-private partnership,” the
opportunity for improved efficiency and greater value may be real
possibility

Identify a method of reimbursement for emergency services

Since the concept of “global payment” is so prevalent among
hospitals today, they may desire to pay for emergency services
by using a flat fee versus a charge per service.
Fire ServiceBased Toolkit
NAEMT – Mobile Integrated
healthcare (MIH)

http://www.naemt.org/MIHCP/WhatisMIH-CP.aspx
Fire Service-Based EMS

Next Steps- SUMMARY
 Determine
 What
need for community paramedic
should it look like?
 Expanded
scope?
 Prevention?
 Medical
Direction– physician driven
 Education
of medics
 Legislation/Regulation
 Identify
 Build
contact in ACO or other agencies
relationships
 Identify
Reimbursement opportunities
Fire Departments
Operational Community Healthcare
Programs
Kent Fire, Washington
Started as a 9-1-1 prevention program (frequent flyers)
 Morphing into preventative health care


Deployed in cars
Use Nurses, Paramedics, EMTs
Navigation to the right setting

Sponsors –




Tri-Med Ambulance - Valley Medical Center - MultiCare Kent Firefighters Foundation - Stafford Suites Assisted
Living - Valley Cities Counseling - Farrington Court
Retirement Community - A & H Stores
http://www.fdcares.com/about-fdcares.html
McKinney, Texas

Pilot started June 2013, now live

Deployed in pick-up trucks

At home patient check-ups for
frequent callers

Chief says: “This is just a natural
evolution of EMS…It is something we
should have been doing for years.”

Two Medical Directors

100% Quality Assurance, once a
week, 8 hours
McKinney Texas Update

McKinney Fire Department CHP program decreased
the number of 911 calls, hospital readmissions, and
ED visits, especially after 120 days.

Among these patients, the potential risk identified
that affected the frequent 911 calls was the number
of calls within the first 30 days after discharge


It is suggested that home visits by CHP APP should be
emphasized heavily during the first month of patient
discharge from the hospital.
The reduction in Fire Engine/Truck calls resulted in
an increase in the In-Service time for the Fire
Equipment.
Salt Lake City, UT

Light response for low acuity patients

Have 40 hour employees meeting with
frequent callers who have been referred by
front-line providers

Constant state of influx

Made difficult due to high homeless
population with no physical address

http://intermountainhealthcare.org/blogs/2014/0
7/911-program-bridges-gap-between-urgent-andemergent-healthcare/
Salt Lake City, UT - UPDATE


As a community partners, the SLC FD and the
Intermountain Healthcare’s North Temple Clinic
recently completed a successful, two-year pilot
program
The fire department meet the needs of people who
call 911, but who did not have life-emergent situations.


Meets medical needs in the home or at appropriate clinics
rather than trying to address issues in a one-time visit at an
emergency department.
SLC Fire Department is now launching a 911 Nurse
Navigator program along with the Utah Hospital
Association, representing hospital systems in the Salt
Lake area.

Services include: scheduling appointments with a primary care
provider, making arrangements for transportation, or
dispatching a community paramedic unit for hands-on help.
Firefighter, nurse practitioner team
up for 'urgent care on wheels'

Won a Medicare Innovation Grant (2014)

The Mesa Fire Department is getting some national
attention for a program that started back in August
2013.

For the past 12 months, Mesa Fire/Medical teamed up
with Mountain Vista Hospital, pairing up a Fire Captain
and a nurse practitioner to respond to low‐level
emergencies.

http://www.mesaaz.gov/fire/
Urban Fire Forum
Position
Statement
Questions?