MIH Implementation guide for Virginia

A proposal:

Implementation Guide for Mobile Integrated Healthcare 
and Community Paramedics in Virginia

Prepared by:

Alan Perry

7/21/2018

Introduction & history

Mobile Integrated healthcare (MIH) and Community Paramedicine (CP) have been around for a long time. They were first conceived to serve rural populations with limited healthcare resources. With the introduction of the Affordable Care Act (ACA) the healthcare system in the United States was transformed by the new emphasis on patient experience, outcomes and reduce costs. The ACA promoted the development of Accountable Care Organizations (ACO’s) which consisted of collaborations across the healthcare system to achieve the results required and the financial incentives. Simultaneously Emergency Medical Service (EMS) systems have experienced explosive growth in call volumes and a general decline in call acuity due to the shift of Primary Care Providers (PCP’s) away from private practice to Emergency Rooms (ER’s) and freestanding clinics in response to increased insurance and operating costs. The gap left in the healthcare system fell largely on EMS which now routinely fields calls for minor ailments and exacerbations of disease processes that would have been handled by the PCP. The situation EMS systems now find themselves in is complicated, and once again we will adapt and bring our resources to bear to address the health of the community in this new environment.

The goal of any MIH or CP program must be in line with the Institute for Healthcare Innovation’s (IHI) triple aim of improving outcomes, reducing costs and improving the healthcare experience for the community it serves. With these general principals the system will work collaboratively with the stakeholders to do what it can to achieve those goals. Patients are the highest priority in any program, you must always do what is best for them through intervention, education, navigation and collaboration with other resources. We have reached a point in the evolution of healthcare that we realize our patients need solutions, not just a ride to the ER. Providers are the backbone of EMS, they are intelligent and capable individuals, that understand the system they currently work in is broken. Empowering these individuals to identify and help connect their patient to resources that will solve their problems long-term, will give them ownership, pride, and an opportunity for professional growth. The EMS system can be directly involved in improving the quality of life and overall health of the entire community while providing services that produce meaningful positive long-term outcomes. By connecting the community with more appropriate resources the system will be less stressed and better able to meet day-to-day demand with its current resources and improve recruitment and retention rates.

The responsibility for developing these  programs in Virginia is defined in the Code of Virginia 32.1-111.3 as the Board of Health, however neither the Board or the State Legislature have taken any action to address this need.  This code also specifies that EMS will transport to Hospitals and "emergency care facilities", seemingly limiting the ability of an EMS system to offer alternative destinations.The development of new programs such as MIH and CP are broadly covered in the The Virginia Office of EMS (VAOEMS) Strategic Plan 2017-2019, in section 4.3.4. but no guidance is provided. The VAOEMS recommends that systems wishing to pursue MIH and CP programs submit an application for a Home Healthcare Licence describing the services to be offered to determine if a Home Healthcare License will be required. 

Where to start

There is no one MIH or CP program that will work for every community, there is too much diversity in our region to come up with a “one size fits all” program. You must make a list of other stakeholders involved in the healthcare of the community including Hospital Systems, Public Health, Public Safety, Mental Health, Social Services, Home Healthcare, Transport Services, Physicians, Insurers, and anyone else with a vested interest in your activity. This step is vital to achieving cooperation and participation in the process. Your success may be limited or even thwarted if you fail to do this. Look at your data, assure that it is valid, and if so, what can it tell you about care gaps and opportunities for your organization, improved public health and costs reduction. A logical approach would be to schedule individual meetings, or small groups, to iron out the general parameters and goals of the program. Bring them together and take an inventory of your regional system assets, and what challenges you may be facing that a MIH or CP program might be able to address.

Discussion with stakeholders

The process of identifying and gaining support among the stakeholders in a MIH or CP program will take some time, perhaps more than a year depending on the level of interest and marketing of the general idea. Your internal stakeholders; City Manager, OMD, EMS Chief, City attorney, Providers, will be the easiest to draw in. The external stakeholders; Hospitals, Physician groups, Home health agencies, Transport, Public health, Social Services, Shelters, and assisted living facilities will be more difficult. You will need to develop contacts within each group that are willing to participate and have authority to make decisions for their respective organizations. You will want to create a limited number of concise talking points to help keep the message consistent and on point. Meeting in smaller like-minded groups will produce more discussion eventually evolving into a core council or board that will remain in an advisory role once your program is up and running. Keep your contact list current and communicate often enough to maintain interest and awareness.

Defining the scope and goals of the program

After sifting through the potential projects, you will need to decide which ones to pursue based on a simple formula categorizing and scoring each one based on value and your ability to successfully accomplish the goal. This should produce an outcome that differentiates between the can-do verses should do, and is preferential to bridging care gaps verses filling gaps with new services. This is a decision you will need to make with your internal stakeholders since they will all be responsible for supporting the decisions and sharing in the consequences. Share your plan with the full stakeholder group for by-in and minor tweaks prior to implementation. Based on what is known about this region an obtainable and realistic program would likely be healthcare navigation accessed by referrals from providers and external stakeholders. It will be simple, of limited scope and demonstrated on a small control group before implemented system wide.

Organization Preparation

Any new program will require thoughtful development of policy and protocols to standardize and define the parameters of the program. These will describe in detail the selection, training and expectations of providers, which patients will be eligible for the program, how they will be enrolled and graduate from the program,what data points will be collected before, during and after graduation from the program, and how the program will be marketed to participants, providers and stakeholders. The training division will develop a training program, and perhaps internships with stakeholders, to educate providers in healthcare system navigation, documentation and patient coaching techniques. A coordinated public education program that integrates program offerings and goals into existing education and marketing efforts will help stimulate interest in MIH programs and bolster the organization's perceived value to the community. 

Program Development

The scope of the program may include clinical services, transportation alternatives and healthcare navigation. It may be a single service or combination of services once fully developed. In the beginning you will want to keep a narrow focus and only consider expansion when you are capable and there is proven benefit. The easiest service to provide is healthcare navigation, it will only require that your provider be able to identify what resources will benefit the patient and facilitate the connection to that resource. An important concept here is that providers should have and expanded role in community healthcare verses and an expanded scope of practice. As the program matures it could take on transportation to alternative destinations such as behavioral health clinics, substance abuse centers, or merely arrange transportation to clinics and urgent care centers. In maturity, and after building on successful collaborations with other stakeholders, services may include community paramedic interaction and intervention with patients suffering from chronic conditions such as CHF or Diabetes to prevent unnecessary re-admissions.

Program launch

After you have developed your program, have all the requisite support systems in place, and have the support of your stakeholders, you can launch your program. Keep it small, limited in scope, and document every detail. Adjustments will be required, with every obstacle encountered you must communicate with the team, work out a resolution, and ultimately do what is best for the patient. Share the experience with all your stakeholders so everyone will be satisfied with the transparency and level of communication in your process. In this way you will create trust and build upon each experience to develop a program everyone is happy with and which meets the goal of improved patient satisfaction, reduced cost and better outcomes.

           

Quality Improvement (QI) & Quality assurance (QA)

With the transition to an outcome-based healthcare system QA & QI programs have never been more important. The fact that a MIH/CP program is something completely new to this region will make accurate collection of data and patient outcomes that much more important. If your data is not solid now, it probably won’t be when your program get up and running, and/or you will have based your program design on data that is flawed. This would be a great time to look at the consistency and quality of the data your system is generating now. Good data will be critical to identifying what your community needs are now and in the future. Once your program is in place that data will be used as a benchmark for your programs impact on community health. Data will also guide your decision to expand the program or create new alternatives.

Cost recovery

A successful program will generate savings for your stakeholders, operational benefits for your organization, greater job satisfaction for your providers, and improve the general health of your community. Insurers, Medicare & Medicaid are beginning to recognize and pay for the types of services described here. You may be able to get start-up funding from your stake-holders if your plan is sound. Every dollar recovered can help fund equipment, supplies, training, support services, and resources for your community. Its money the community has already paid-in through taxes and insurance premiums which they have every right to permit the system to recover. Cost recovery has been advocated for across the country in both career and volunteer systems for these very reasons. The act of not using cost recovery is, in effect, throwing away the community’s taxes and insurance premiums and giving them back to insurance companies and the government at the expense of the local EMS system. It takes a certain amount of fortitude to confront and educate the public, but the logic of the argument is sound and must be made unless you have a plan to fund your system as an essential public service like Police & Fire strictly through local taxes.

Conclusion

This evolution of EMS will bring it into the broader healthcare system, improve the quality of life within the community, reduce the cost of healthcare within the community, and improve patient outcomes while bringing EMS providers to a place where they will have greater influence and ownership in the healthcare system. Mobile Integrated Healthcare and Community Paramedicine are here to stay, we can take the necessary steps to implement a model for that in Virginia, or we can wait for it to be pushed on us without our input. You choose.

Loyal Customer Program

Loyal Customer Program

for

Your Emergency Medical Services & Fire Department

By Alan Perry

October 21, 2013

Introduction

Most EMS agencies & Fire Department's are aware of the growing momentum of changes affecting the delivery of pre-hospital EMS as a result of general healthcare reform and specifically the Patient Protection and Affordable Care Act. These departments 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. They realize that the healthcare environment is becoming more dynamic and that their organization, 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 the 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 un-billable 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 identify a 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, the hospital systems and your chief officer are all stakeholders in this immediate process. They 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 its 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 hopefully 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 (CQI) 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. 

Good hunting,
Alan