Are we Ready for Mobile Integrated Healthcare?

Are we Ready for Mobile Integrated Healthcare?

by Alan Perry

12/25/2013

edited 6/24/2018

In 2013, The Tidewater Regional EMS council Medical Operations Committee convened a work-group for the purpose of exploring MIH/community paramedicine options for our region. Included in the group were a number of local EMS service managers and chief officers, TEMS officials, Hospital system liaisons and a few field providers such as myself. below is a letter I wrote to the group after meeting for several months, when it became clear it would no go anywhere this time around. From the beginning I had concerns about inclusion of stakeholders who were conspicuously absent from our meetings and our collective view of their importance in our process. At the time we had an opportunity to move our region forward into a new era of EMS practice, one that is now sweeping the country with some outstanding results.

I have been examining Mobile Integrated Healthcare (MIH) and most of its variations since I was first exposed to the concept in the context of Accountable Care Organizations (ACO’s) nearly six years ago. This occurred while studying its application in reaction to changes in Oregon State law at that time, in a hospital based EMS system. It seemed to be a perfect fit, since the entire process was contained within a single organization. 

Over the past five years I have examined other systems outside our state, and looked at the Patient Protection and Affordable Care Act (ACA) in some detail. I don’t think we can deny that the ACA was the driving force for community paramedicine and MIH. Do we understand fully enough what the intended goals of the legislation are? Do we have a specific goal for where we will fit in?

At that time I think it was clear we did not.  Initially we failed to bring stakeholders in so we could develop a better sense where gaps existed and where collaboration could be possible, as a result the process failed.We waited several years for some direction on this and some are slowly working out local solutions that fit each unique circumstance. 

In our region the majority of Emergency Medical Services (EMS) are provided by the Fire Service,Volunteers and Municipal EMS. We have the added challenge of having multiple competing hospital systems. We all have our own internal challenges, our own perception of where best to start, and are bound by our Operational Medical Director’s (OMD’s) and the Virginia Department of Health (VDH) position in the matter. Are we all at a place where we can state honestly that we are meeting and exceeding the needs of our patients and providers by providing the best evidence-based care and public education, without the additional burden of MIH? If we continue to press forward into a new and uncharted area of service without first mastering our current responsibilities we are in essence putting lipstick on a pig.

My greatest fear is that MIH will take away from resources needed to properly train and maintain our emergency response capability, our core service. This same concern is voiced by officials in the Department of Transportation in response to suggestions that EMS be moved from there to the Department of Health and Human Services. Their fear and mine is that it will degrade and take away from the core services we are expected to provide for trauma and emergent medical care. Would a better use of these resources and time would be to invest them in areas where we already know they will have a positive impact on our performance and patient outcomes, namely public education and provider training?

It seems to me, and perhaps also the VDH, that MIH is a unique and separate service, outside the normal definition of EMS. Perhaps more closely related to Home Healthcare. In the evolution of the healthcare system locally, as attempts are made to comply with the ACA and the financial pressures it brings, I believe many of the larger institutions will take on the roles of ACO’s and improve patient outcomes, without the assistance of EMS, through better patient education and follow-up. EMS agencies and this council are not in a position to influence the decisions made by these large businesses that now have significant financial incentives to change the way they do business in a radical way. In this economic view we cannot hope to be the tail that wags the dog.

When this work-group first met I suggested that we seek input from the stakeholders immediately to determine our direction. I also suggested that we have some clear areas that we can start working on that we already own the responsibility for; Public education and provider support. I would be pleased if we could get back to those points in the near future.

When we successfully meet with our partners and the other stakeholders and honestly discuss the possibilities for improving population health, healthcare experiences and reduced costs, I hope we will be better prepared to adapt to need without any preconceptions. New opportunities present themselves with each new day, private insurers and legislators are changing the environment to allow MIH and Community Paramedic programs to become a reality with hope of sustainability.

Respectfully,

Alan

Can you hit a moving target?

Can you hit a moving target?

Alan E. Perry

November 17, 2013

Anyone can tell you that in order to hit a moving target you must compensate for the motion of the target and the trajectory of the object you intend to hit in with. It can be tricky enough when you know the values for these variables, compensating for them, leading your target and adjusting for elevation, windage, air density and gravity. It is nearly impossible, except for dumb luck, to accomplish a hit if one or more of these is not known, or worse is constantly changing. This is the circumstance EMS leaders are finding themselves in as they try to grasp concepts like community paramedicine, mobile integrated healthcare and all of their variations being explored throughout this country and elsewhere.

EMS is no stranger to change; it began in 1967 with an article titled Death in a Ditch, our growth as a viable public safety essential service, the 1996 EMS Agenda for the Future, its follow-up implementation guide and the 2007 EMS at the Crossroads describing the future of healthcare. We can’t say we didn’t see the changes coming; many organizations have been quietly and productively working at solving problems, filling service gaps and improving the quality of their services for many years. The rest of us are now staring at the ambulance barreling down on us and trying to decide which way to run.

The Patient Privacy and Affordable Care Act (ACA) is not new, it has been around and its consequences known for several years. This is the latest variable added to the changing world of EMS, many of its objectives are compatible with the needed changes to EMS that were recognized in 1996, yet we have still not acted on the majority of them. These were once stationary goals that EMS alone sought to achieve, we are now so far behind that the change is now being pushed down on us from the Federal Government! What has happened to us? We are so worried about studies, stakeholders, regulations and politics that we can’t even do the simple and easy things we have known we need to do for decades.

So, about that target, what is it? Do you want to just look good, or actually do good? We know that better patient outcomes are at the top of the list closely followed by greater healthcare system integration and lower costs, all identified in 1996 but now also required to obtain the objectives of the ACA. We have now lost the initiative; hospitals are improving readmission rates on their own, hospice and home health care organizations are filling the gaps between primary care and the hospital more fully, both are reducing costs and improving the quality of care for the patient. It may be that EMS will not play much of a role in this new system as we had hoped despite finally coming up with innovative ways of delivering care.

Let’s not forget the taxpayer, citizen’s and city managers out there, will they support increased services and increased expenses for EMS systems to duplicate services they have until now thought to unimportant to develop on their own? Will you be able to convince hospital administrators that you can do a better job than they of reducing readmission rates? Will your regulatory bodies allow you to expand your roles in the face of all the other changes going on in healthcare at the moment? Can all this be done quickly enough to even make a difference, or will you be driven to provide whatever services all these other parties decide you are competent to perform? As you can see we are not just trying to hit a moving target, we are trying to hit multiple moving targets that are rapidly changing direction, as it sits I think we will go home empty handed unless we change our way of thinking and our tactics.

I suggest that we go back to basics, clean up our house, and begin working on developing real and meaningful strategies that will improve the quality and value of our services whether or not we can develop new ways of delivering that service. Work on developing your staff, cultivate your leaders, and train your providers with the best programs available.  Educate your public, policy makers and stakeholders. The true value of public education is severely underappreciated by EMS, look at the outcome, and resources, dedicated to public education in fire prevention, why is EMS any different. This is a target we can hit.

Be Safe,

Alan

TEMS Community Paramedicine Workgroup Meeting 11-12-2013

Tidewater EMS Council

Community Paramedicine Workgroup

November 12, 2013

1305       Welcome and Introductions

                Review of meeting notes from October 11, 2013

·         Accepted-unofficial

                Updates from EMS symposium meetings and classes

·         VAOEMS advisory board- (Jeff Meyer) Chesterfield program will start up next month. Their focus is on frequent flyers/loyal customers, an education program and the CHF patient population. They will start training next month with a two week course involving social services, CIT training, and rounds with a cardiologist visiting CHF patients. The program will use 3 FT paramedics and one program manager. They seem to be going for the same type of service we are trying for.

·         Home health challenge; license or not? OEMS is waiting on opinion from AG office. The advisory board has not yet met with Home-Healthcare providers. Individual agencies may get their own license but are taking a “wait and see” approach.

·         State workgroup- (Tom Schwalenberg) State workgroup is still in the “trying to figure it out” phase.

·         MEDSTAR- (Thom Schwalenberg) Met with Director of Med-Star. Examined the Med-Star process and what they learned. They started dialog with stakeholders got their foot in the door and facilitated a collaborative vs. adversarial relationship to identify service gaps in the community.

               

                General Discussion

·         Are we headed toward a regional CP program or and individual agency approach, a single call, single service may work better.

·         Council may consider a coordination role for a regional program with a central dispatch point following a nurse triage of each call with other alternative destinations using EMD.

·         We should examine MEDSTAR and RAA nurse triage systems.

·         RAA is no longer doing this due to problems with their system.

·         (Melody Siff) Wilmington and other systems have had growing pains- we should expect the same.

·         Hospice patients should also be considered.

                Education/Awareness Sub-Group

                MOC Presentation discussion

·         Need to add hospice patients to proposal.

·         Community Paramedic curriculum may be available locally if adopted. Distance learning is available approx. cost is $3000 per student.

·         Need to provide examples of successful programs to demonstrate what it will look like, what they did and why it worked.

·         Recommendation will be to develop a regional program.

·         Benefits of program are: Single contact point, greater efficiency, improved agency cooperation, Shared patient data.

·         Needs to be condensed to a 10 minute presentation

·         Need to define what “community paramedicine” is, what the pros/cons are locally, and provide a recommendation.

·         Legal and regulatory concerns related to expanded role vs. expanded scope, this is where we are today.

·         Concerns that workgroup is setting program up for an adversarial vs. cooperative pathway for the regions program by not getting stakeholders involved in the process yet.

·         (Travis) We need to get all involved parties input first- before moving forward.

·         (Schwalenberg) Informally, this information is being communicated.

·         (Foster) Is there potential for TEMS/PEMS cooperation?

·         Can this presentation be given to OMD’s?

·         This presentation must include an advisory that the next step must be identifying all of the stakeholders, educating them and do GAP analysis.

Regional Community Paramedicine Model (handout)

·         Document submitted to group for review and comment

               

                Review of data supporting scope of problem

·         Readmission reports; handouts for Bon Secours data (Travis), CGH data (Schwalenberg).

·         CHF patients with readmissions from Portsmouth, Chesapeake, Norfolk. Data is unconfirmed due to inconsistent coding

·         Data seems to suggest the problem is real but may be declining

·         Various hospitals have taken independent actions themselves which have had a dramatic effect on the significance of the problem.

·         Data from agencies going to Travis for case studies

                Committee Reports       

                None

                OEMS Report

                None

                Old Business

·         Will this workgroup request from MOC to be formalized as a committee?

·         Will wait to see what/how the group and data are received.

·         Stakeholder sub-group will be Jennifer Foster, Darren? And Liz?

                New Business

·         OMD meeting will receive community paramedicine update information.

·         MOC presentation will not be presented to OMD meeting.

                Good of the order

               

1438       Adjournment

Next meeting will be December 5, 2013 at 1300 in the TEMS conference room.

TEMS Community Paramedicine Workgroup Minuets 10-11-2013

Community Paramedicine Workgroup Meeting

Friday, October 11, 2013

1300-1430

Tidewater EMS Council Office, Chesapeake, VA

1305       Welcome and Introductions

 Thom Schwalenberg, Chair opened with introductions and review of agenda.

Discussion on Workgroup minutes v. notes

Meeting minutes will be kept, though not required for a workgroup, in anticipation that the workgroup may become a committee at some point. There have been inquiries from others about meeting activity and a need for documentation. Alan Perry volunteered to record meeting minutes, Wendi Ambrose will assist.

Discussion on Workgroup membership

The Chair asked what the make-up of the workgroup should be and if a minimum level of participation should be required from jurisdictions. A list of current participants and meeting attendees was provided along with contact information.  It was suggested that each affected agency should, at a minimum, send a representative to these workgroup meetings.

Mr. Porter reminded the group that all activities of this, or any TEMS activity, are always open to the public.

 Jason Stroud asked about committee representation at MOC meetings, it is the intent of the workgroup to request elevation to committee status at the December MOC meeting.

Discussion on Purpose Statement

The Chair asked if our current purpose statement was adequate, or if it needed any changes. After reviewing the document as recorded from the previous meeting records all agreed that it was adequate and correct. The discussion moved to the need for purpose statements for project and stakeholder sub-groups as well.

The chair asked if the workgroup may be overstepping its purpose. The group agreed that we should focus on developing good recommendations for the MOC in two areas; who are the stakeholders, and what projects would be desirable and feasible for our region.

Education/Awareness Sub-Group Report

Presenters Ray Willet & Melody Siff reviewed a power-point presentation they created for the workgroup explaining what community Paramedicine is, that it involves expanded roles for providers, and why it is needed. A review of community Paramedicine benefits and challenges, the benefits to hospitals in achieving the “triple aim”, payment models, Medicaid, pilot programs and cost savings occurred. The presentation is intended to be present at the MOC, comments from the floor suggested that the term “preventable ED transports” needs to be defined.

The presenters turned to some of the frequently asked questions about community Paramedicine;

·         CP programs use an OMD group for supervision and medical control, not a single OMD. Hospitals will be concerned with revenue and patient demographics.

·         How will enrollees be targeted?

·         How will CP positions be staffed?

·         How will agencies be compensated?

·         It will involve and expanded role for providers not and expanded scope of practice.

·         CP programs may require changes to State legislation.

The group discussed the goals for this presentation to the MOC. It was recommended that the presentation be shortened and more focused addressing the legalities more specifically, the benefits to hospitals, and describe what CP is and is not to effectively sell the concept. It was suggested that we need to get the stakeholders behind us early.

Stakeholder Sub-Group report

No Sub-Group members present- no report available

Virginia OEMS Report

Jay Porter provided information on the options facing a CP program. If scheduled home care will be involved each agencies, or a broader association must possess a home healthcare license. There are only two other options, they are; getting a variance from VAOEMS, or sub-contracting for another entity. A variance is unlikely.

Wendi Ambrose resurfaced the discussion of the  council serving  as an entity for the region and become licensed. Questions from the floor asked if that would limit the activities we could pursue and/or upon us up to additional inspections. More research needs to be conducted as to cost and liability.

New Business

The question asked was how to proceed for a pilot program. The discussion quickly turned to target patients, terminology and definitions. It was suggested that terms such as “frequent flyers”, “preventable ED transports” and other unspecified terms be given the standard definitions already ascribed to them by functioning programs such as Med-Star, or large prevailing studies on the subject matter,  to avoid confusion and allow for standardization of data.

The Chair asked what programs should be presented to the MOC , through some discussion the group agreed to a single target group to keep our focus narrow. CHF patients were selected and the defining criteria for identifying them were discussed so that data can be collected to explore the potential of the programs effects. Asthma patients and Diabetic patients with a history of falls were also considered.

Sharing of data for research may be a problem, agencies need to examine and/or modify business agreements with healthcare facilities to facilitate the sharing of PHI for research.

Chairs will make contact to Travis Mitchell of Bon Secours ,  and CRMC contact once data needed to capture is determined. Thomas Schwalenberg will make the spreadsheet for agencies and hospitals to fill in data.

Agencies represented at the meeting proposing to share data were: Chesapeake, Portsmouth, Virginia Beach and Suffolk.

Closing

In preparation for the presentation to the MOC workgroup members from each agency will be collecting data from records generated  January through March of 2013 to be reviewed for CHF Hx, chief complaint SOB w/HTN, use of CPAP and/or Lasix pre-hospital. Hospital data will also be collected to identify all CHF readmissions and ED visits whether transported by EMS, POV or private ambulance. A dollar cost per readmission (average) will also be calculated based on hospital data and EMS billing figures since the cost needs to be quantified in both dollars and patients.

Next Meeting

The next meeting will be November 12, 2013 at 1pm at the TEMS office.

A better product

When I wrote the EMS Manifesto I came to the realization that the right things don’t just happen, they frequently require a little push, or in some cases gentle pressure applied relentlessly. In my efforts to break down our old business as usual approach to things I am sure my publications have offended some people, perhaps being perceived as critical or negative to some. My intent is, and always has been, to broaden the discussion of the issues affecting us all in the public safety arena as well as improving the quality and efficiency of the services we provide. Too frequently I have heard co-workers, supervisors and even chief officers deride new programs and policies because of the lack of participation and input they were able to provide in the process. It is the consensus of the business and leadership community, that inclusion and participation in these processes produces both a better result, and greater acceptance and ownership of the finished product. It remains my goal to remain engaged and share these processes with those that will be affected, the general public, and others working in our industry to improve the understanding, participation and quality of our product. We work and live in a much more dynamic and open environment than in the past, it should not be perceived as a threat, it is an opportunity to gain that engagement and produce a better product. I hope you join me as we embark on our journey, remain open and engaged, and marvel at the results.

Rules are no substitute for training

Rules are no substitute for training

Alan Perry

September 29, 2013

Rules are no substitute for training. Having been responsible for monitoring and correcting performance issues in field EMS I can tell you that it is always better to recognize the true source of the problem. It has been my experience and expectation that my providers want to do the best they can for our patients, they recognize when they need to brush up on a skill and come forward either requesting additional training or offering to conduct it themselves. In those rare circumstances when a problem develops that is evident through the QA process my first approach is always to examine the training. If it is an isolated event or a recurring problem with a single provider counseling is warranted which may include some one-on-one training. If it is presenting as a more widespread problem then clearly it is more of a training failure, either communication of the protocol or procedure, or the expectations. In either case merely writing a new policy to enforce an existing standard of care is not effective.

Performance gaps will present themselves in the dynamic environment that is modern EMS, the challenge for supervisors and system managers is to not add to the complexity, which is already growing, by supporting the on-going training needs of our providers. I know money and resources are tight but the potential liability to you, your providers and your organization could be much more costly. If you look at it from a risk avoidance standpoint it makes economic sense. Healthcare is becoming more performance & outcome oriented, our customers are more aware of the standard of care, your providers do what they do because they want our patients to have the best outcomes, from a moral & ethical standpoint a quality training program makes sense.

A quality training program should include periodic review, training & testing on all protocols, procedures & operations, this should be coupled with competency verification of essential & basic skills conducted at least twice a year if not quarterly. Such a program assures and verifies competency of these low frequency/high risk skills, giving them confidence in the face of their most difficult calls and improving the overall performance of your service. Don’t forget to add a personal touch, your providers need to know your expectations, the OMD’s expectations, and those of your supervisors, they should all have face time in the training process. Do you and your OMD know all of your providers by name? They will be more likely to respond positively to a request from you, or your agency’s OMD if they know you personally. They just want to know you value them and the work they do.

TEMS CPM Meeting september 25, 2013

TEMS CPM Meeting

September  25, 2013       

Conference presentation- Ray Willet, James Holzer, immediate change is needed, EMS will not be the same in 5 years. 110 working programs in usa US.

Transistion from EMS to Unscheduled EMS.

Manage high risk refusals and other non-transports

Plan/schedule non-emergent patients

Separate can do from must do

Not home health, resource for home health

Region needs single contact for CPM services

Educate other healthcare providers about role of EMS/CPM

EMSinitially designed for trauma emergencies, that is no longer the case

If we do not embrace CPM, hospitals will.

Fewer paramedics increases paramedic skill levels

Benifits/Risks not fully understood

wake County NC system example

The 3 R's= respond, redirect, reduce

Community health, substance abuse, fall prevention, HTN, CHF, DM

CPM fits EMS scope of practice model

Quick Legal View

Potential for expanded liability

No major legal obstacles

No percieved increased liability

Other effected parties may not feel the same way

Some large losses

lawsuits are successfull only 25% of time

No claims agiants any CP or MIHP programs

Defininition of scope of practice not limited to EMS regs, grey areas exist

EMS regs state we must operate within the agency EMS license relating to circumstance in which care is provided.

Scope of Practice v Standard of Care

State of Va

Chesterfield process asked to slow down

m.Berg recieved call from home health nurse in Roanoke, Carrillion EMS acted independently and offended because they did not communicate

Scheduled care may violate EMS licensure requirements

VAOEMS will not allow waivers for this, a home health license must be obtained currently

Failure to communicate with stakholders has been primary failure so far

VAOEMS suggests moving slowly, without exceeding scope of practice

(note: this meeting had no other stakholders in it)

There may be some mounting opposition to CP activities in Virginia

Alexadria may have a program model utilizing PA to manage program

Suggest any proposal go up through TEMS with stakeholder endorsments to VAOEMS

Current VA regs prohibit scheduled home based EMS services

Home health has a 24-48hr window post discharge before they can see a home patient

*russ blow-include in correspondence

Closing

We know what needs to be done

We need to bring in the other stakholders within the region

Start with somthing small and achievable

need 2 working groups, one for stakholders, one for workable ideas

Target date for presentation is November 2013

What is cost per patient, to hospital? to EMS agency?

Next meeting October 11, 2013

EOM

There's No Time

Don’t Re-invent Community Paramedicine, There’s no time!

By Alan Perry

September 25, 2013

It baffles me that the issues of community paramedicine, integrated healthcare and implementation of the EMS agenda for the future are still not resolved. Here we are, less than 30 days from major portions of the Patient Protection and Affordable Care Act (PPACA) being implemented, with most agencies having no clue how they will be affected and how/if they are going to make any changes. We have got to start thinking outside the box (pun intended). As we gather to meet and discuss these eventualities we need to stop trying to re-invent the whole process every time. There is a large body of work already completed working programs in place by nearly every variety of EMS system and free money to make it all happen. Duplication of effort is never a good idea, we must learn quickly to take the good work already done and apply it to what we are doing, or need to be doing.

Here’s the problem, the PPACA does not specify how medical care will be provided it only specifies the desired outcome and the penalties for not achieving the “triple aim”. So everyone involved in the process, especially those with the most to gain or lose, are moving aggressively to develop programs with little consideration on the effect on EMS services. The EMS community apparently does not feel threatened by this, much like our apathy about the recommendations of the EMS agenda for the future we think we have all the time in the world and that our federal or state officials will tell us how to proceed. I can tell you now that the Federal and State officials tasked with oversight of EMS don’t have a plan. The hour is growing very short; we are approaching a point where we will have to transition from being proactive to being reactive.

The best publication I have found so far is from the National Consensus Conference on Community Paramedicine, the meeting in October of 2012 produced an excellent summary of how a program should work that can be easily tailored and implemented incrementally by any EMS service. I am aware that the National EMS Advisory Council (NEMSAC), State offices of EMS, Local EMS councils and individuals are also working on their own plans, expending great amounts of time and effort to go through the same process already completed by acknowledged experts. Why? I suspect part of the problem is that it is not a priority. EMS still takes a back seat to other emergency services in many locales. Those tasked with this project may not have funding, and although grants may be available it may not be a priority for the senior administration.

Any program of this type must go through some necessary developmental steps that don’t necessarily need to occur in a chronological order. While you are obtaining the data to quantify the problem you can also be developing a general selection and training program for your providers, having dialog with the other stakeholders and creating your grant requests, and building the infrastructure to support it. This is possible because of the large body of work already completed and some known variables for your program. We must be seen by our healthcare partners, the public and policy makers to be taking positive steps to move our systems forward toward improving outcomes, reducing costs and improving the overall healthcare experience.

Acknowledge the quality of the work already done, use it, build upon it, and modify it. Build upon this foundation of what will be a new way of doing business, embracing the goals of the EMS agenda for the future and the PPACA. They are defining what we do and what the public needs and expects from us.

References:

Patterson DG, Skillman SM. National Consensus Conference on Community Paramedicine: Summary of a Expert Meeting. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; Feb 2013.

DOT, HHS. Innovation Opportunities for Emergency Medical Services: A Draft White Paper. NEMSAC, July 2013.

Goodwin J, Finding a New Seat at the Healthcare Table, Best Pactices in Emergency Medical Services, Vol. 16, No. 7, July 2013

How to create a Loyal Customer Program

Loyal Customer Program

for

Your Emergency Medical Services & Fire Department

By Alan Perry

Introduction

The EMS & Fire Department is aware of the growing momentum affecting the delivery of pre-hospital EMS as a result of general healthcare reform and specifically the Patient Protection and Affordable Care Act. The department would like to begin working on solutions that are easiest to achieve and can be accomplished without major changes to existing policy or major program development. The department realizes that the healthcare environment is becoming more dynamic and that the department, and any new ideas, must be flexible and adaptable. EMS systems are frequently misused and abused by a small portion of the patient population; the premise of this program is that this unnecessary and unproductive behavior can be easily corrected without any major changes to or normal operational pattern by simply providing a little patient and public education among this target group. Ideally this program will include the voluntary cooperation of the loyal customer, their primary care physician and the EMS provider. It will incur no additional cost for the EMS agency, and may actually prove to save money by avoiding unnecessary and unbillable transports. It will have the added benefit of being an anchor point for validating efficacy through research allowing expansion of the program if needed to address hospital re-admission rates and other targets of the Patient Protection and Affordable Care act.

Program Development

·         Quantify the problem

·         Identify the stakeholders

·         Develop a policy, procedure & infrastructure

·         Conduct a pilot study

·         Analyze the data

·         Get stakeholder feedback

·         Monitor the results, seek continuous improvement

Quantifying the problem

We all have our suspicions about the number of patients that routinely misuse and abuse the 911 EMS system, we know their names, where they live, and what their primary complaints are. In order to prove that a change in our system is having the intended effect we must know exactly what the problems is, the number of transports, the number of patients, the primary complaints must all be documented and analyzed to produce a measurable problem. Typically most EMS systems do not do anything about this type of problem until it becomes a major issue, due to this and the changing shifts and personnel the problem may be greater or lesser than imagined. A quick and dirty way to accomplish this might be to conduct a retrospective analysis of EMS calls identifying specific addresses, patients and chief complaints to produce a good starting point. A better way would be to add a few targeted questions such as: Do you have a pcp? When were you in the hospital last for this problem? Do you have any means of transportation? These examples of questions could be used to flag your potential loyal customer for review.  

Identifying the stakeholders

You, your providers, the patient, the patients physician, your OMD and your chief officer are all stakeholders in this immediate process and should be heard before a plan is developed, again after it is finished, and ongoing as it is implemented and refined. For this to work, everyone needs to be happy with the process and the intended results. There may be other parties you will need to involve such as public and/or mental health and your state or regional EMS office. You must explain in basic terms what you hope to accomplish, a reduction in misuse and abuse of the 911 EMS system, and ask each what your agency can do to achieve that goal that can fit within the confines of a public and patient education program.

Developing policy, procedure and infrastructure

After quantifying the problem and collecting stakeholder input you can begin the process of creating an outline of your program’s policies, procedures and infrastructure needs. Your research will identify what the specific problems may be, your program should be targeted to achieve improvement in those specific areas and also seek to improve the experience for patients and providers.  A mechanism must be in place to fully record and document the presenting problem, what interventions were done, and ultimately whether or not the situation improved. Privacy policies and law will need to be examined to determine what data can be used to identify loyal customers and track their progress. Voluntary participation of the patient and the patient’s primary care physician will likely be needed to avoid any legal problems. The role of the provider will most likely be that of a health coach, monitor and recorder working in partnership with the patient’s physician and/or your OMD. A schedule or process must be created and supported for providers to perform routine or PRN health checks and follow-up. The same data used to identify your problem will be used to document it effectiveness

Do a Pilot Study

Start with a small area, a single station or district with a clear problem that this program should be able to address. Train your personnel, identify and enroll your patients and physicians and kick it off. This is a good time to be hands-on, check with the providers and see how it went for them, with the patient and make sure it was a positive experience, and with the patients physician. They all must be satisfied with the way it is working or it must be modified. Document every contact with your usual PCR. Collect all the relevant NEMSIS data and any pertinent data relevant to your program objectives.  Once you have worked the bugs out of your program in the pilot (3-6 months minimum) you should have enough data to determine if it can be applied to the rest of your system or expanded to others.

Analyze the Data

Within 3-6 months you should have enough data to determine if your program is having the intended effect, and you may have identified several new target populations/sub-populations as well. If your program is producing the intend result you must be able to prove it with the data before expanding or continuing with it. If the results are mixed or show no/negative change try to identify why, this is a good time to go back to those stakeholders to discover where the program may have failed and get good suggestions about how to improve it. Make sure you are measuring the right metrics, any improvement in patient outcomes, healthcare experience and cost reduction are meaningful and positive results.

Stakeholder Feedback

Go back to your original stakeholders and any new ones you may have discovered, revisit the initial objectives of the program of reducing EMS system misuse and abuse by your loyal customers. Are there any concerns now? Are there any suggestions for improvement? Are there any unforeseen outcomes or consequences? Is everyone happy? Any concerns or negatives here must be addressed  before the program can grow, your stakeholders will remain your primary source of feedback about the performance of your program, they will be of great value in maintaining the program’s responsiveness and relevance as circumstances change.

Monitor the results, seek continuous improvement

Once your program is up and running you will still have to go through much of this process again as new information becomes available allowing you to tailor your approach to each new patient, refining and validating new approaches that produce better or more efficient results. If successful you will hopfully draw the attention of our healthcare partners who may seek to involve you with their patients as well or borrow ideas from your program. Keep in mind that it must be a dynamic program that can adapt to the needs of the patient, the providers and the requirements of local, state and federal law. Continuous Quality Improvement (CGI) will keep your system effective, efficient and popular with your stakeholders.

Summary

A Loyal Customer program is an easy to achieve first step for 911 EMS systems that are not sure where to go or what to do next in the face of healthcare reform and the Patient Protection and Affordable Care Act. Instead of waiting around for healthcare changes to be forced upon us, it seems prudent to start taking some positive action that will improve the quality of our service and the outcomes of the patients we serve. A by-product of positive action is public support, goodwill, and increased pride among your workforce for being proactive. 

Full report on September, 2013 NEMSAC meeting

Summary Report

from the September 5&6, 2013 meeting of the

National EMS Advisory Committee

By Alan Perry 9/7/2013

I embarked on a journey to Washington D.C. this week for the September NEMSAC meeting. I was really interested in finding out what was going on at the national level with all the recent changes facing EMS, and I wanted to get the information from the source, unfiltered and without editorial spin. I ponied up the time and the money to make this happen and cover my expenses for the two-day meeting. Please keep in mind that what I am presenting here is largely what I heard, not necessarily an absolute account of the events or statements made. I have tried to the greatest extent possible to be inclusive and factual in my accounts, and have made some of my own personal thoughts known as well. The meeting agenda, which is determined by the Designated Federal Official (DFO) and the committee chairman, was published about ten days before the meeting and included items that both my agency and the regional EMS council have been struggling with for some time. Since the council consists of a broad spectrum of EMS players, all considered experts in their field, it seemed like the perfect place to get the best answers and understand how Federal agencies NHTSA, FICEMS and HHS will be likely to respond. As it turns out it is a good deal more complicated than that, so I will start buy trying to explain this bureaucracy to you. The information I gathered in the meeting is useful if it is taken in context, but this organization does not operate like a fire department, rescue squad or business, has no real authority, and is only permitted to act in an advisory capacity to NHTSA, HHS & FICEMS. All discussions, decisions and information gathering must be done in a public forum to assure transparency, which is a good thing, but it does slow things down.

Prior to the first days meeting the DFO, Mr. Drew Dawson, introduced himself to me and welcomed me to the meeting, I found out rather quickly that getting any comment about pending legislation either officially or as a personal opinion was not likely to happen from a government official. Mr. Dawson, and the chairman Aarron Reinert, maintained a fair and even hand throughout the two-days of the meeting and represented DOT, NHTSA and NEMSAC very well. Other officials in attendance, but not directly involved with the committee, were a bit more forthcoming and even offered assistance to my agency or personally if additional information was needed. All of the council members, federal officials and organization representatives in attendance were very approachable and eager to provide their insights if asked. Other members of the NEMSAC included

Representatives from volunteer EMS, EMS research, EMS educators, EMS practitioners, EMS medical directors, consumers, trauma surgeons, hospital administrators, local EMS directors, emergency nurses, air medical, state highway safety, 911 dispatchers, private EMS, emergency physicians, state EMS directors, data managers, public health, fire-based EMS, state and local legislature, hospital based EMS and pediatric emergency medicine. There were others in attendance from the IAFF, NAEMT, NREMT, IAFC, NASEMSO, HHS, NHTSA-EMS, DHS, DOT, DOD, local fire departments & myself who were there to present, observe and comment.

Mr. Dawson opened the meeting by stating that he was impressed with the council’s performance and reminded attendees that the council will affect planning at FICEMS. Mr. Reinert stated FICEMS is expressing great interest in the activity of NEMSAC and is looking for 3-5 specific items to work on. Terms for some members are about to expire, new and different members need to step up and bring new issues to light as they are found. He reminded members of the three core values of NEMSAC; Visionary, Strategic and Diligent. After the initial introductions and housekeeping were out of the way the agenda kicked off with the federal updates from DOT, DHS USFA & HHS.

Federal Updates

DOT-  Keith Williams spoke briefly emphasizing that EMS extends beyond NHTSA, the purpose of the Federal Highway Administration (FHWA) is to reduce injuries and fatalities on all public roads with prevention being key in the design of the State Highway Safety Plans (SHSP’s) and includes EMS in the four E’s enforcement, engineering, education & emergency medical services. Mark Kehrli, Director of FHWA, showed a brief video and explained the importance of getting all highway workers including police, fire, and EMS and recovery services on the same page when it comes to safe and efficient scene clearance. FHWA has a new traffic incident training program out with the goal of training 50,000 responders within 3 years. This program is already being offered in southeastern Virginia.

DHS- Bill Sector, DHS liaison of the NASEMSO, suggested that the NEMSAC continue to look for practical solutions to known problems and continue to be the voice for EMS including support for community paramedicine. There is a need for greater integration among fire/police/EMS at major events such as mass shootings, a problem well known in southeastern Virginia. Common problems are still with communications and lack of knowledge of other services terminology and tactics. There may be a need for EMS to start entering scenes in less than ideal circumstances if lives are to be saved, perhaps adopting the philosophy of fire-fighting where more risk is acceptable where lives can be saved. Human trafficking is becoming a greater problem, EMS is in a unique position where they may be the first to identify it, a new program called the “Blue Campaign” is attempting to address this, it can be found online at DHS.gov\bluecampaign.

USFA- Mike Stern; NFA is developing more courses for EMS recognizing that EMS is 80% of what most fire services are doing. Since the NFA is not a traditional supplier of EMS education perhaps the council can push the information out, the classes are free. As courses pick up EMS instructors will also be needed as well as ideas for useful new EMS courses.

HHS- Greg Margolis; Referenced the innovation white paper relating to increased EMS demand incidents (MCI?). He introduced web resources for public heath emergencies (phe.gov) and the Hospital Preparedness Program (HPP). Announced operation bioshield, which is an EMS countermeasure involving stockpiling of WMD medications (similar to MMRS?), he reminded the council that preparation for major incidents both hospital and pre-hospital remain woefully inadequate. A reminder was given that the PPACA provision for open market health insurance opens October 1^st.

Stakeholder reports

DHS- Bill Seifarth; discussed the need for changes in how EMS approaches mass shootings and IED’s, the activities of Police/Fire/EMS need to be better integrated and new tactics such a tourniquets, hemostatic agents and the use of body armor need to be considered more fully. Response and incident management training, NIMS standards, plans and exercises need to occur to prevent interoperability failures. The traditional role of EMS staging until the scene is “safe” will cause significant loss of life and increased injury severity in mass shootings and IED events due to the nature of the injuries, there needs to be dialog to resolve this. Chief Sinclair, representing fire-based EMS, commented that the NEMSAC should lead the change in doctrine and policy related to these events. The Chief’s remarks and the concerns of DHS echo the concerns I reported to my agencies command staff after a school shooting exercise we conducted several years ago. In those comments I suggested adopting the same doctrine we apply to a fire incident where risk is based on the probability that lives will be saved, put simply we risk a lot to save a lot, we risk nothing to save what is lost.

NASEMSO- Dia Gainor, representing the National Association of State EMS Officials, provided information on EMS workforce guidelines. There is a new publication titled National EMS workforce data definitions which identifies the characteristics of the EMS workforce as well as those seeking EMS education or employment.

DoD- Marion Cain stated there is difficulty transitioning EMS providers from the military into civilian EMS upon their separation from the armed forces. Correcting this problem will improve employment opportunities for veterans. Gaps exist in the training provided by the military and civilian EMS, the goal of the proposal is to provide gap training and there are currently 280 in a pilot program. Bridging this gap and allowing these veterans to transition to civilian employment in EMS is a priority of the White House and the First Lady. Military EMS training is not accredited and recertification is not required, DoD will be looking at fixing these issues so personnel have recognized credentials.

White Papers

The next segment of the NEMSAC meeting was presentation of white papers, contracted by the NEMSAC, for the purpose of getting expert and unbiased information on topic of concern to the council. The white papers commissioned were; Pre-hospital EMS as Public Good and Essential Service, Research in Pre-hospital Care: Models for Success, Emerging Digital Technologies for EMS and 911 Systems and Efficacy of Pre-hospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage.

Pre-hospital EMS as a Public Good and Essential service- This draft White Paper was authored by Mike Milligan of the National Academy of Public Administration from a purely economic viewpoint. It did not translate to the common conception of terms such as “good”, “club” or “public”. If that was not confusing enough the author took a round-about way of getting to his conclusion at one point suggesting that EMS was a common good, police service a public good, and fire service a club good. This understandably confused and in some cases angered those in attendance. The conclusion of the paper was that EMS is a Public Good and an essential service, and identified how some public administrators may view it. It was the consensus in later discussions that the paper needed some clarification to avoid the possibility that some portions of the paper could be taken out of context and be seriously damaging to the causes of both fire and EMS services.

Research in Pre-hospital Care; Models for Success- This draft paper, authored by E. Brooke Lerner and funded by NHTSA and the EMS for Children Project, centered on the correct way to conduct clinical trials and the obstacles that must be overcome. Some identified barriers include; funding, consent, ethics approval, training of EMS providers and researchers, lack of relationships, political & social risk, reliance on EMS providers and/or hospital staff, other researchers. The paper is well written and would make a good resource for anyone considering an EMS research project. The author provided this additional resource; clinicaltrials.gov.

Efficacy of Pre-hospital Application of Tourniquets and Hemostatic Dressings to Control Traumatic External Hemorrhage- The authors recommend a systematic literature review, the military and PHTLS already recommend and include these tactics in their TCCC curriculum but civilian evidence and research are lacking. The efficacy of TQ’s compared to pressure alone, the efficacy of specific TQ products, the efficacy of hemostatic dressings compared to standard dressings and the efficacy of specific hemostatic products all need to be studied. These will be looked at by the authors with an additional report forthcoming and the results will be made available to field EMS providers and EMS physicians. This is one of several exercises, which to me; indicate some detachment of this committee with other researchers and fields of practice. TQ’s and hemostatic agents have been proven in the specific areas of concern, namely IED’s and mass shootings, by the military and are the basis of their inclusion in the TCCC program. My concern is that the committee may be expending precious resources by duplicating the efforts of others.

Emerging Digital Technologies in EMS- Benjamin Schooly and Thomas Horan co-presented this paper and asked the NEMSAC to provide feedback before the paper is published. The authors inform us that new technology has reached the level described in the EMS Agenda for the Future with application in injury prevention, response, treatment, training, education & communication. There are significant application and expansion gaps that need to be filled. A common view among EMS systems is that integration needs to occur with other public safety and healthcare partners to fully develop this potential. Solving this issue will have positive health benefits but new skills must also develop to manage the new technology. All stakeholders must work toward creation and adoption of common data elements and information systems so the entire EMS event can be captured and studied. Some of the obstacles that are present include privacy concerns, technology costs, integration and infrastructure; there is no guarantee that new technology will save money.

I found this portion of the meeting to be very informative, at times also frustrating and confusing. Hearing well compensated private and federal officials stand up and declaim some of the same ideas I and others have advocated for years, makes me wonder if the only ideas that are ever heard are the ones proffered by those having influence and authority regardless of the quality of the idea. This makes me question if what I have to say will ever make a difference. Don’t get me wrong, this type of organization must exist, those acknowledged as experts must speak and provide an outlet and connection with policymakers, but it also sorely needs more public participation and scrutiny by EMS providers.

Public Comments

The brief public comment period before the sub-committee meetings occurred with several speakers; Mr. Linde representing the NAEMT stated that there needs to be more dialogue between fire and EMS. A representative from NOAA asked the council what other products they should work on that could be of value to responders other than heat indexes and air quality. A representative from Latrobe University in Australia stated that EMS in the United States could learn a few things from Australian EMS and offered to facilitate some discussion.

Sub-Committee meetings-PPACA

I attended the sub-committee presentation and discussion on the Patient Protection and Affordable Care Act (PPACA). This meeting was led by Chief Sinclair, with NHTSA representative Noah Smith in attendance. The two biggest issues for this sub-committee were the untoward effects of the PPACA on volunteers and integration of EMS into the healthcare system via community paramedicine, mobile integrated healthcare, or some other vehicle. Chief Sinclair asserted that this sub-committee will likely need to be a standing committee to facilitate the still developing effects of PPACA on EMS, and that the focus of the committee should be bi-directional addressing both the effects on the EMS systems as well as the effects on employees and volunteers. The committee discussed at length the transition challenges to mobile healthcare, the effects of healthcare consolidation, and issues with tax liability and/or penalties for volunteers due to PPACA. Many questions were generated with an obvious need for follow-on discussions once the needed information is obtained.

Discussion (Saturday September 6, 2013)

 The morning before the committee reports I ran into a federal official at a coffee shop, I took the opportunity to ask (again) for some comment or opinion on HB809 and some aspects of the ACA. The response was solidly in support of NHTSA retaining its relationship with field EMS out of concern for retaining existing relationships within the federal government and preserving the highway safety and response characteristics of EMS in vehicular accidents. The lack of structure the PPACA provides in the development of new EMS systems was also acknowledged. I also found source material to present to the PPACA sub-committee authored by the AHRQ (Agency for Healthcare Research and Quality) titled Community Paramedicine Evaluation Tool, which our council is using as a template to develop a CP program of our own and may be useful and trump the need of this sub-committee to write a best practices document.

White Paper discussions:

EMS as an essential public service- General discussion by members;

·       EMS has characteristics making it both an essential public service and a public good (economic definition). It does require public funds to operate effectively. This is primarily due to the need for preparedness and services provided without payment.

·       Two distinct cost factors; readiness and marginal, which can be funded separately as a more logical way to provide funding.

·       Some exceptions noted in the report which separates fire and ems improperly and classifies them differently.

·        Economic definitions v common definitions can be misleading to the public and may send the wrong message. The document is helpful in that it provides a better understanding of EMS functions in economic terms which are the language of government and financial entities, but it does need more work in both detail and depth of comparisons.

·        The paper also needs to recognize that various EMS systems operate in different realms of the economic models presented and cannot all be lumped together as a homogeneous group.

·       The fire service is improperly classified as a club good, not a public good, the fire service is largely tax funded and therefore is clearly a public good and also an essential service. The fear is that the document, which is considered to be incomplete and inaccurate, if published will damage both fire and EMS goals immediately and could be used as a tool by those wishing to push other incompatible agendas.

·       The document will be available on ems.gov when complete.

Active Shooter/IED's-

·       Training is needed; it is a tactical issue more than an operational one and as such should not be dealt with by this council.

·       The use of TQ's in some situations is prudent, but needs further refinement. Again this organization should not be concerned with field protocols.

·       The initial discussion yesterday also recognized the weakness of the relationship between police-fire-ems regarding terminology and operations at multi-casualty incidents and ems recognizing that the scene safety component may become more variable with some risk needed to save lives in MCI circumstances.

·       The council was reminded that this issue was brought forward by the deputy director of FEMA; there may be a need for this council to look above the specifics and start looking at the cooperative aspects of the problem rather than the specific tactics and protocols.

Sub-committee meeting reports:

NEMSAC Process sub-committee- endorsed NEMSAC process document which is a guiding document for the council defining how the committee will operate to both members and the public.

EMS education Agenda for the future sub-committee- The sub-committee will develop a document requesting suggestions for minimal updates needed to reflect the new education standards, federal legislation, and the EMS education agenda document.  The sub-committee will ask for all comments without restriction openly, and will be making request at all stakeholder meetings this fall. This sub-committee will review these at the December meeting and make recommendations to NEMSAC based on the current state of implementation. A motion to have the Chair draft a letter requesting suggestions from stakeholders, and review responses at December meeting, allowing public comment and discussion, was approved.

PPACA sub-committee- The sub-committee created a group to research best practices in community paramedicine, and will bring forth best practices to be published as an advisory. The sub-committee recognized the work of previous councils in addressing concerns with CMS and the need for repeating/duplicating work. The council may need to re-evaluate the work of the previous finance committee recommendations for EMS funding. The council should create an advisory to IRS on effects of PPACA on volunteer EMS. Much discussion ensued regarding the effects of PPACA on EMS, and the desire by the council to here from some federal partners on the specific effects that may be felt by EMS. It is recognized that the law, and the practice of EMS, will be evolving and ongoing. Chair request input from all about any good material relating to this topic.

EMS Agenda for the future sub-committee- This was a formative meeting.

Safety sub-committee- This sub-committee is waiting for the publication of a new safety position paper, it will be reviewing that and meeting with stakeholders to gain consensus on the next steps. The safety problem is not quantified and the sub-committee will need data to base its decisions on. We may need to work on education as a primary means of obtaining results. NREMT is pushing team and resource management training as a potential solution. IHST is joint federal/HEMS effort to improve safety, and can be used as model for improving EMS safety.

Public Comments:

IAFF- A representative of the IAFF requested that the NEMSAC discard, abandon or defund the White Paper titled Pre-Hospital Emergency Medical Services as a Public Good and Essential Service citing the potential for harm to the collective goals of both EMS and FIRE services if published.

NAEMSO- The NAEMSO is working on legislation that will grant professional recognition of EMS certifications across state lines. The final draft should be available in early 2014.

NAEMT- Supports the activities of the NEMSAC, there is a need for EMS research training.

NFPA- Suggested the use of social media to get people more involved in the activity and discussions of the council. Reminded the council that NFPA-1917; Ambulance standards, is being updated. The final standard should be published in March, 2014.

NVFC- The White Paper titled Pre-Hospital Emergency Medical Services as a Public Good and Essential Service needs to be more straight-forward in language. The inclusion of fire and police in the report is not helpful and creates distinctions between the three public safety branches.

General public & NEMSAC member comments:

·       The White paper titled Pre-Hospital Emergency Medical Services as a Public Good and Essential Service needs work.

·       NEMSAC needs to facilitate Mobile Integrated Healthcare Practice (MIHP) discussion.

·       Medical Directors need to be involved in MIHP discussion and can help facilitate it.

·       The AARP support EMS public education, MIHP & PPACA

·       NEMSIS data is growing, what are we going to do with the data?

·       EMS education is moving toward better critical thinking and less cookbook medicine.

·       MIHP education needs to start occurring now.

·       As a result of PPACA more agencies are using part-time employees. What are the ramification for EMS professional development and workforce retention?

·       Out of hospital roles of EMS providers will be changing, more involved in general healthcare and public education.

·       Suggestion that the duration of NEMSAC meeting be increased to accomplish more, acknowledging the complexity of the decision making process.

·       Suggestion that the NEMSAC look at Israeli EMS practices as a model for response to mass-shootings and IED events.

·       NEMSAC must initiate conversation on EMS evolution.

·       There is a need for EMS provider population analysis.

·       There is a shortage of EMS providers in Hawaii; the state offers incentives to EMS providers.

The meeting concluded following these closing statements. Overall I found the experience very informative. I also found it very supportive of the ideas I already have and those I am working on in my own agency. I suspect any organization attempting to influence policy at this level will be slow to act, often working on a parallel tract with proactive EMS systems across the country. The council should recognize that and seek to get ahead of the local movements and encourage federal actions that can facilitate it. It is clear no one will be able to fully predict the effects of PPACA, but this legislation is poised to completely change the way EMS is funded as well as its basic function. The NEMSAC is developing its position slower than the changes are occurring. It may consider having a more concentrated focus at future meetings to get ahead of it. I look forward to continued interaction with the NEMSAC; it has the potential to be more influential in advocating for responsible EMS policy if it can become more focused.

AP