I Am Worried.
Can you Send Someone to
See My Mom?
Kristofer Smith, MD, VP
Jonathan Washko, AVP
Asantewaa Poku, Clinical Data Analyst
Elizabeth Quellhorst, Administrative Manager
Session Code A25, B25
Presenters have
nothing to disclose
1
Session Objectives
• Identify the key operational strategies necessary to build programs to
keep high-risk frail elderly from going to the emergency room
• Review lessons learned from a collaboration between an advanced
illness management program and a community paramedicine program
aimed at reducing admission rates for the high-risk frail elderly in the
community
• Understand how to ensure the financial viability of clinical
collaboratives focused on high-risk patients by taking advantage of
health care reform and/or partnering with insurance companies
2
Problem Statement
• Seniors with multiple chronic conditions in an advanced
state with functional impairment have frequent
deteriorations in health status which requires meaningful
24x7 clinical responses.
• These high risk, high cost populations have extreme
difficulty getting to traditional outpatient services and
therefore rely heavily on emergency department and
hospital care.
• Interrupting this cycle through at home clinical support
programs could alleviate suffering, improve quality and
decrease cost.
3
Advanced Illness Management
– House Calls Program
Background
Complex medical management for more than 1,000 patients in Queens,
Nassau, and Suffolk counties with multiple chronic conditions and functional
impairment
•
Interdisciplinary care teams, which include physicians, nurse
practitioners, social workers, and medical coordinators deliver primary
and palliative care in the patient’s home in an effort to:
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Understand wishes of the patient and family (advance care planning)
Maintain or improve functional status
Reduce unnecessary utilization or unwanted care
Increase days at home
Allow for death with dignity at home
Care for the whole person: social work and care coordination
5
Advanced Illness Management – House
Calls Program Background
House Calls Patients, N= 1071
Age
110 Oldest
84
Average
21
Youngest
69% Female
31% Male
= 10 patients
Nassau, Suffolk and Queens counties
* November 2014 Census
Advanced Illness Management – House
Calls Program Background
House Calls Stats*
* November 2014 Census
Program Background
• Established in 1993, providing air and
ground BLS, ALS, SCT, CCT and 911
services
• 600+ Emergency Medical Technicians
and Paramedics
• Largest health system based ambulance
service in New York Metropolitan area
and one of the largest in the United
States
• Duly accredited by the Commission on
Accreditation of Ambulance Services
(CAAS) and the National/International
Academics of Emergency Dispatch,
Accredited
Center of Excellence (ACE)
8
Program Background
• Over 110 available response units
across New York City, Nassau, and
Suffolk
• More than 135,000 requests for
service per year
• 24x7x365 Fault tolerant services
• Advanced Medical Priority Dispatch
System with Dispatch Life Support
• Clinician answers every call utilizing
call prioritization & triage system
• All ALS system operates under a High
Performance EMS operations model
• Reliable, clinically appropriate
response time
9
Unique, Innovative &
Integrated Solution
• Comprehensive Mobile Integrated Healthcare /
Community Paramedicine Program
• Telemedicine
• Centralized Command and Control System
• Integrated into EMS System as a Clinical Safety
Net
• Advanced Analytics
• Integrated Quality Assurance / Improvement
10
Key Mobile Integrated Healthcare
Community Paramedicine Program Elements
• MIH Framework
– Regulatory Approach
– Specialized Training
– Specialized Equipment
• EMS Operations
–
–
–
–
–
Command and Control
Call Center Integration
High Performance EMS
Marginal vs. Specialized Approach
IT Systems Integration
• Clinical
–
–
–
–
Telemedicine, On Line Medical Control
Formulary, Diagnostics & Treatment Modalities
Death at Home with Dignity
Quality Assurance / Improvement
12
Mobile Integrated Healthcare
Community Paramedicine Program
Non-Transport Solution Options
Diagnostics
Treatments
Formulary
Expanded Physical Assessment
Basic Airway Management
Magnesium Sulfate
Ipratropium Bromide
SAO2
Suctioning
Solu-medrol
Sodium Chloride
ETCO2
Oxygen Therapy
Glucagon
Diazepam
Blood Glucose
Medical Equipment Adjustment
Nitroglycerine
Fentanyl
Temperature
Burn Care
Metoprolol
Diphenhydramine
Weight
Hemorrhage Control
Labetalol
Midazolam
Vital signs
Invasive Tube Assessment
Odansetron
Morphine Sulfate
EKG Rhythm Interpretation
IV Catheter Placement & Removal
Dextrose 50%
Lorazepam
12 Lead EKG
NG Tube Placement & Removal
Albuterol
Environmental Assessment
Pain Management
Tetracaine
Medication Administration
Naloxone
In Home Assistance
Aspirin
IV Fluids
Furosemide
13
Mobile Integrated Healthcare
Community Paramedicine Program
Transport to ED Required Solutions
Diagnostics
None Require Transport
Treatments
Formulary
Advanced Airway Management (ALS)
Atropine
BiPAP / CPAP
Dopamine
Severe Hemorrhage Control
Adenocard
C-Spine Immobilization
Epinephrine
Defibrillation / Cardioversion
Calcium Chloride
External Pacing
Vasopressin
IO Placement
Amiodarone
Long Bone Splinting
Diltiaizam
Sodium Bicarbonate
Etomidate
Vecuronium
14
Integrating Telemedicine
• In 2014, the Verizon Foundation awarded a grant to the North ShoreLIJ Health System
• LG G2 wireless devices and lines of service were provided as in-kind
support to allow for secure video conferencing (WebEx) between the
paramedic, OLMC MD, and patient/family during Community
Paramedicine responses
• Launched in September 2014, integration of telemedicine allows for
more accurate assessment and enhanced “physician extender” ability.
15
Comprehensive
Mobile Integrated Healthcare Community
Paramedicine Program
• Year One Program Results
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Operational Metrics
Clinical Metrics
Outcome Metrics
Quality of Care & Patient Safety Metrics
Financial Metrics
16
Operational Metrics
There were a total of 2,889
House Calls patient calls
over the course of the first
year
Community Paramedicine
was activated for 386 of
these calls (13.4%)
88 Community
Paramedicine calls (22.8%)
resulted in transport to the
hospital
Community
Paramedicine
Responses
Time (min)
Average CP
Response time
22
Average CP time
on scene
65
Average task time
80
Over 60% of the calls occurred during House Calls non-business hours
17
Operational Metrics
CP Call Volume by Month
70
60
50
40
30
20
10
0
18
Clinical Metrics
EMD Coding by Category
respiratory/
cough/mucous
public assist/no medical
7%
concern
5%
behavioral
abnl
2%
labs/vitals
5%
cardiac
4%
pain/discomfort/reaction/
uti
13%
GI/nausea /vomit
10%
dizzy/weak/lethargic/am
s/ neuro/dehy/intk or
output issues/fever/
diabetes
45%
19
catheter issue
1%
circulatory/cellulitis/skin
8%
Clinical Metrics
EMD Problem/ Nature Transport Avoidance
Transport Avoided
Transported
Sick Persons (Specific Diagnosis)
Breathing Problems
Unable To Determine
42
Falls
20
5
Chest Pain (Non-Traumatic)
14
7
Unconscious/Fainting (Near)
15 2
Hemorrhage/Lacerations
9 8
Stroke (CVA) 10 1
Abdominal Pain/Problems 7 3
Convulsions/Seizures 5 1
Heart Problems/AICD 5
Diabetic Problems 4
Traumatic Injuries (Specific) 2
Psychiatric/Abnormal Behavior/Suicide Attempt 2
Unknown Problems (Person Down) 1
Overdose/Poisoning (Ingestion) 1
Headache 1
Back Pain (Non-Traumatic or Non-Recent…1
Cardiac or Respiratory Arrest/Death 0
20
72
64
22
22
17
Clinical Metrics
EMD Problem/Nature by Non-Transport Type
CP: Evaluated
CP: Evaluated & Treated
CP: Pronouncment
CP: Evaluated & OLMC Care Plan Change
CP: Evaluated/Treated/Pronouncment
Sick Persons (Specific Diagnosis)
36
Breathing Problems
22
Unable To Determine
26
Falls
14
4 2
Cardiac or Respiratory Arrest/Death
22
Chest Pain (Non-Traumatic)
8 4 2
Unconscious/Fainting (Near) 5 7 3
Hemorrhage/Lacerations 5 0 4
Stroke (CVA) 5 4 1
Abdominal Pain/Problems 3 3 1
Convulsions/Seizures 2 21
Heart Problems/AICD 12 2
Diabetic Problems 1 3
Traumatic Injuries (Specific) 2
Psychiatric/Abnormal Behavior/Suicide…2
Unknown Problems (Person Down)
Overdose/Poisoning (Ingestion) 1
Headache 1
Back Pain (Non-Traumatic or Non-…1
21
16
11
24
26
5
12
1
Clinical Metrics
Emergency Medical Dispatch Priority Codes
ECHO
DELTA
CHARLIE
• Choking with complete obstruction
• Allergic reaction with ineffective breathing
• Respiratory/cardiac conditions with ineffective breathing
• Allergic reaction with AMS
• Breathing problems with AMS
• Breathing problems color change
• Burn ≥ 18% of body area
• Choking with abnormal breathing
• Abnormal breathing conditions
• Cardiac problems (with history)
• Headache with speech problems
• Overdose with Altered Mental Status
• Stroke conditions
BRAVO
• Unknown conditions
• Possibly dangerous trauma injuries
• Non-imminent labor
• Serious hemorrhage
ALPHA
• Low acuity response with no priority symptoms
OMEGA
• Response level for special referrals
• Poison control center or nurse advice
• Non-priority complaints
22
Clinical Metrics
Transport Avoidance by EMD Priority Code
Transports avoided
Transported
0.00%
73.3%
26.7%
80.5%
19.5%
67.5%
32.5%
78.7%
21.3%
100.0%
71.2%
28.8%
23
Clinical Metrics
EMD Priority Code by Non-Transport Type
CP: Evaluated
CP: Evaluated & Treated
CP: Pronouncement
CP: Evaluated & OLMC Care Plan Change
CP: Evaluated/Treated/Pronouncement
100%
26%
32%
48%
38%
24%
63%
12%
27%
26%
57%
35%
6%
4%
1%
11%
8%
82%
62%
26%
24
12%
Clinical Metrics
Administered Treatment by Disposition
Evaluated & Treated
Evaluated, Treated & Transported
IV catheter/saline lock placement
32
Medication administration - Intravenous
35
Oxygen therapy (blow by/ nasal cannula/nebulizer/trach
mask)
22
Medication administration - Nebulized
Medication administration - Oral
16
3
Hemorrhage control
Medication administration - Intramuscular
5
5 1
2 3
Medication administration - Sublingual
Pain Management
22
4
2
BVM ventilation 1
Medication administration - Intranasal 1
25
13
19
5
Clinical Metrics
Administered Medication by Disposition
CP: Evaluated & Treated
Albuterol (0.083%)
Sodium Chloride 0.9%
Furosemide
Ipratropium Bromide
Morphine Sulfate
Solu-medrol
Aspirin
Nitroglycerin
Dextrose 50%
Ondansetron
Glucagon
Metoprolol
Naloxone
Fentanyl
Diazepam
Labetalol
CP: Evaluated, Treated & Transported
15
14
13
6
6
4
10
6
8
6
4
1
3
1
4
3
1
1
2
2
2
1
1
1
1
26
Clinical Metrics
Follow-Up Planning
Non-Documented
5%
Scheduled CP
follow up
2%
House Calls
follow up –
Telephonically
14%
No Follow up
needed
55%
House Calls
follow up Patient Visit
24%
27
Quality of Care & Patient Safety
Avoidable Transports by Presenting Problem
Transports
Presenting Problem of Potentially Avoidable
Transports
Hypotensive w/o IV access
1
Hyperglycemia
1
Lacerations
1
GI/Constipation
1
UTI
1
61%
13%
26%
Foley Catheter/Pubic Tube issues
3
Labs needed
Non-avoidable transports
Patient/ Family choice
4
Peg Tubes
5
Pneumonia/Resp. Infection
6
0
Potentially avoidable if
received in home care
28
1
2
3
4
5
6
7
Quality of Care & Patient Safety
RCA to avoid future Transports
34 (38.6%) of the 88 CP transports were potentially avoidable
Reason for Transport
# Occurrences
Potential Solution
Patient/Family Choice
11
Patient/Family Education
Labs needed
4
I-STAT/ Point of Care testing
Peg Tubes
5
Ultra Sound/X-ray, Training for CP
Foley Catheter/Pubic Tube issues
3
Training for CP
Pneumonia/Resp. Infection
6
I-STAT/ABX/Chest X-ray
UTI
1
I-STAT/ABX/Foley replacement
GI/Constipation
1
Laxative, Training for CP
Lacerations
1
Suture training for CP
Hyperglycemia
1
Insulin
Hypotensive w/o IV access
1
Conscious IO access
29
Quality of Care & Patient Safety
Physician Survey Responses
Did the information provided by the Community Paramedicine evaluation
change your medical management?
Yes
118 (74%)
0%
•
•
•
•
•
20%
No
41 (26%)
40%
60%
“Patient had large laceration on foot and it would not have been washed
and dressed properly (with a pressure dressing) if the Community
Paramedic was not there.”
“The negative neurological exam helped remove possibility of CVA.”
“I was not going to prescribe antibiotics until the evaluation by CP medics
revealed abnormality of skin.”
“The patient complained of being short of breath but her normal oxygen
saturation provided reassurance that she could be treated at home.”
"I was going to order an x-ray, which would have meant waiting 5+ hours
for results. But one leg was actually found to be rotated and shorter than
the other, so immediate transport was arranged, avoiding hours of
suffering."
30
80%
•
•
•
•
100%
Death
pronouncement
Reassurance for
overwhelmed or
distressed
caregiver
Public assist
Patient is on
hospice; has no
intention of
being
hospitalized
Quality of Care & Patient Safety
Physician Survey Responses
If the Community Paramedicine evaluation had not been available, would
you have advised the patient to go to the ER?
Yes
110 (69%)
0%
20%
No
50 (31%)
40%
60%
80%
100%
• “I definitely was going to send the patient to the ER if Community Paramedicine
had not been available.”
• “The Community Paramedics’ evaluation gave me more confidence in my plan. I
would have recommended that the patient go to ER based on the symptoms
described by the patient’s daughter.”
• “I originally was going to have the patient stay home, but then found that she was
somnolent and hypoxic so I sent her to the hospital for further evaluation.”
• “Patient was recently accepted onto hospice and wanted to stay home.”
31
Quality of Care & Patient Safety
Physician Survey Responses
Did video monitoring enhance your evaluation of the patient during the
Community Paramedicine response?
Yes
59 (81%)
No
14 (19%)
0%
20%
40%
60%
80%
100%
• “It showed the intensity of the bleeding from the patient’s trach.”
• “I was able to see urine and that the foley was draining despite what the patient stated.”
• "Video conferencing allowed me to see my patient pre-Lasix. Since she is my patient, I
was able to see that she was more lethargic than usual, despite the paramedic's report
that she looked 'fine.' I could see her change from baseline status. She appeared more
energetic after the Lasix was given, and she was able to stay at home."
• "I was able to see on video conference that the patient was flat in bed, and
recommended he be raised HOB to help with cough. I decided not to prescribe
Albuterol."
32
Quality of Care & Patient Safety
Patient Satisfaction Survey Results
• 107 surveys were mailed to the patient home
following a Community Paramedicine (CP)
response from 9/17/14 to 12/5/14.
– Surveys were not mailed to patients who passed away.
– Patients who had multiple CP responses within a 1-3
day window received one survey.
• 32 surveys were completed (30% response rate)
– 5 (16%) were completed by the patient
– 27 (84%) were completed by a family caregiver
33
Quality of Care & Patient Safety
Patient Satisfaction Survey Results
I was satisfied
with how the oncall House Calls
The Community
provider and
My goals for
I would use the
Paramedics
Community
medical care
Overall, I was
CP service in a delivered highParamedics
were accounted
satisfied with my future medical quality services
managed my
for in the
CP experience.
emergency.
and care.
medical issues. treatment plan.
100%
80%
60%
28 (93%)
27 (90%)
2 (7%)
3 (10%)
28 (93%)
28 (93%)
27 (90%)
40%
20%
0%
Neutral
2 (7%)
2 (7%)
Agree
Strongly Agree
34
2 (7%)
1 (3%)
Quality of Care & Patient Safety
Patient Satisfaction Survey Results
If the Community Paramedicine Program did not exist, what would you have
done during your medical emergency?
Dialed 911
23 (62%)
Went to the
Emergency Room for
evaluation or
treatment
11 (30%)
Waited to
see if I
got better
3 (8%)
0%
20%
40%
60%
80%
100%
• “Could not have asked for more. Could not be more grateful for be in the House Calls
Program.”
• “I (the caregiver) was completely satisfied with the doctor and Paramedics in the prompt
care my father received, from the time the doctor called me with the results of his blood
work, to his care by paramedics, to his trip to the ER.”
• “I was very impressed with the program. I am an RN and I truly appreciate the level of
professionalism and caring that was shown to my father. Bernard (our paramedic) made my
father feel at home immediately. This is a wonderful program.”
• “I am the daughter of an elderly patient. The House Calls program and Community
Paramedics have been an absolute lifesaver - for all of us. With your amazing care, we
have been able to keep my mother at home, out of the hospital, comfortable, and incredibly
35
well cared for.”
Outcome Metrics
Admission Rate of Transported Patients
CP Transport Inpatient Admission Rate
Avg. CP Transport Inpatient Rate
Non-CP Transport Inpatient Admission Rate
Avg. Non-CP Transport Inpatient Admission Rate
110%
100%
100%
100%
90%
100%
100%
92%
88%
83%
80%
80%
83%
70%
82%
69%
60%
50%
50%
November December
2013
2013
January
2014
February
2014
March
2014
April 2014
36
May 2014
June 2014
July 2014
August
2014
September
2014
October
2014
Community Paramedic Program
Financial Metrics
• Costs based on leveraging existing CEMS infrastructure
• Calculated using fixed and variable costs per visit
• Approximately $200 per visit @ 1.25 hours which
includes:
– Vehicle, maintenance and fuel
– Salaries, wages and benefits
– Medications, supplies and equipment
– Dispatch services and specialized software
– Integrated call services
– Other general expenses
37
Payment
Avoidance
Estimations
38
Marketplace Challenges
Government
Payment
Reductions
Payer Mix Shift
to Gov’t Payers
& Exchanges
Readmission
Penalties
Increased
Consumerism
and Price
Transparency
Downgrades/
DenialsRAC/MAC
Inpatient
Volume &
Case Mix
Declines
Increased
Provider
Competition
39
Health System Strategy
Strategy
40
Risk Based Contracts
Program Type
Description
Full Risk
• Receive all or portion of premium.
• Responsible for total cost of care.
Shared Risk
• Share in upside/downside savings/losses relative to
pre-established spending target.
• Responsible for all or portion of medical spend.
• Quality Gate
• Eligible to share upside savings with payer relative to
Shared Savings
pre-established spending target.
• Quality Gate
41
Margin Impact
SourceAdvisory Board. The Essentials of Risk Based Contracting
Comprehensive
Mobile Integrated Healthcare
Community Paramedicine Program
Program successes to date
• 24x7 on-demand Community Paramedic response
effectively and efficiently fills care gaps in the home
• Significant decrease in transports to the ED yielding
subsequent payment and cost avoidance
• High patient satisfaction levels
• Zero adverse clinical outcomes
• Low cost of services compared to acute care setting
• Opportunities exist to lower transport rate even
further
43
Comprehensive
Mobile Integrated Healthcare
Community Paramedicine Program
Program challenges to date
• Physician understanding and adoption of EMS
capability and scope into workflow
• Scope of practice / formulary limitations
• State regulatory hurdles & limitations
• Payer source (internally funded R&D project)
• Data integration amongst disparate systems
44
Questions?
45