Sunday, June 24, 2018

Mobile Integrated Healthcare in Virginia

The Mobile Integrated Healthcare in Virginia
By Alan Perry
updated June 24, 2018

Introduction
I embarked on a journey to explore what has come to be known as Mobile Integrated Healthcare Practice (MIHP) several years ago. The concept was outlined in the National Academies Institute of Medicine book Emergency Medical services at the Crossroads and The National Highway Traffic Safety Administrations publication EMS agenda for the future, but not named or structurally defined by either. The concept has been under development by a number of hospital and pre-hospital systems for several years with some success. With the passage of the Affordable Care Act and the formation of Accountable Care Organizations (ACO’s), additional monetary incentives have been created, and the concept has gained significant momentum and support. I have, for several years, realized that the future of EMS rested in the improvement of the relationship and integration between healthcare providers and systems across the continuum of patient care. An article I wrote in early 2012, EMS Manifesto describes my vision then as it does now. I am very excited to see the concept taking shape, of course this type of concept will have application in very different ways depending on patient population, the type of EMS and hospital systems that are involved, and the input and participation of local and state governments.



The goals of Mobile Integrated Healthcare
The general goals of Mobile Integrated Healthcare are: to reduce healthcare costs, decrease inappropriate system use, prevent emergent hospital re admissions and improve hospice results through appropriate use of  the whole spectrum of healthcare. The “triple aim” as described by the Institute for Healthcare Improvement (IHI) , improving the healthcare experience, improving health and reducing costs are met as well as the defined goals of Accountable Care Organizations (ACO’s), delivering high quality care and reducing costs. Patients should receive the care needed in the most appropriate way, improving health and the quality of the experience. For providers it should produce greater job satisfaction, greater flexibility in providing care and more options for professional development. For EMS services this will  require additional responsibility and integration within the healthcare system. It should produce a reduction in non-emergency calls, frequent users, and permit cost recovery for alternative service delivery such as treat and release, or transport to alternative treatment centers. For hospitals it will require more cooperation with local EMS and medical record sharing. The benefit to hospitals and healthcare systems should include reduce inappropriate ER visits, reduced re admissions and availability of resources for true emergencies. Insurers, including medicare and medicaide have to start looking at EMS as a useful partner in achieving the IHI triple aim. EMS is well positioned to make this all happen but legislation and cooperation with the other players is proving to be the greatest obstacle. With cooperation, the entire system should work more smoothly, costs will be reduced and quality of care improved.

Who will play a part in Mobile Integrated Healthcare?
Patients, healthcare providers, EMS & fire chiefs, physicians, administrators, politicians, EMS agencies, regional EMS councils, hospitals, ACO’s,  public health, social services, mental health, state EMS offices, insurers, Medicaid, Medicare and the public will all have to contribute, collaborate and cooperate to develop a Mobile Integrated Healthcare Practice (MIHP) that accomplishes the goals described by the IHI as well as addressing local needs. I suspect that the diversity of the stakeholders will play a large role in the ability, or inability, of any locality to reach an agreement and develop a meaningful program. ACO’s that fall under one organizational umbrella will have a much easier time developing and implementing a MIHP provided they have all, or a majority of the required components to make it work. In the TEMS region of Virginia there are several independent hospital systems, volunteer, public and fire-based EMS systems, various private ambulance and home health organizations, local and state government entities that provide components of the system we will need to build.

Some potential obstacles
Politics, power, money, ignorance and apathy frequently prevent progress. The primary stakeholders in MIHP will be the EMS systems, hospitals, home health agencies, social services, public health, legislators and insurers. Our region has several EMS systems that are very diverse in their basic structure. We also have multiple hospital systems in the region that have differing organizational goals and strategies. Success may require funding through insurers both public and private who have been slow to adopt, and pay for, alternative treatments or destinations for EMS other than an ER. Our biggest challenge will be reaching agreements that will allow us all to work together cooperatively and creating a legal framework that supports it. We have now been through the first two stages of grief, denial and bargaining, and must now move on to acceptance, eventually reaching a point where we are anticipating the benefits of our success.

Success stories in Mobile Integrated Healthcare Practice
MedStar-Fort Worth, Texas
Public utility model EMS system providing service to a large metropolitan and suburban area.

Wake County, NC EMS

Alexandria, VA Fire Department
Fire based EMS system


How should or local system proceed?
I will not represent myself as knowing enough about every aspect of this subject to try to write an implementation guide for localities, Tidewater or the State of Virginia. To my knowledge there is not a universally applicable model or implementation guide that will work for every system. We must find our own way together, with every stakeholders input, to find the application that works best for our patient population, healthcare facilities, legislators, emergency services and healthcare providers. There are some general first steps and considerations needed to begin putting it together. The majority of functional MIHP programs are hospital based or public utility model EMS systems, neither of those models is universally applicable to the current system in the Tidewater EMS council. At this point, with a lack of favorable legislation, insurance billing practice reform, and sincere commitment from the State office of EMS, solving the problem currently rest with individual localities. The good news is that the body of literature and evidence surrounding MIH programs have improved greatly and many brave and determined souls in the realm of EMS are finding creative ways to start chipping away at this issue. It all starts with discussion and identifying the needs of the patients and the system. Stakeholders will make or break you, do not fail to include them in the discussion early. Stakeholders hold the key to enabling a working solution.

Conclusion
The tidewater region has unique challenges to the implementation of MIHP. The need for a program such as MIHP has been acknowledged for several years with little action. Changes in healthcare law, specifically the affordable care act, provide sources for funding with collaboration across healthcare disciplines. Until a Statewide or Regional solution can be developed, it will be up to individual agencies to start working with their stakeholders to develop solutions that work for that system. Our sacred oath as healthcare providers is to do no harm, by that we must infer that we do what is best for the patient, in this case correcting the known problems in our delivery model. By doing so, we will improve the quality of the experience, the health of the patient, and the sustainability of our system.



References:

Institute of Medicine, Emergency Medical Services at the Crossroads weblink
http://www.iom.edu/Reports/2006/Emergency-Medical-Services-At-the-Crossroads.aspx

National Highway Traffic Safety Administration, EMS Agenda for the Future weblink
http://www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf

Institute for Healthcare Improvement website

Accountable Care Organizations, Centers for Medicare and Medicaid Services website

NAEMT website, Community Paramedicine

Virginia Office of EMS, Division of Community Health and Technical Resources

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