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.

The Old and the New; Richmond Ambulance Authority

The Old and the New;

Richmond Ambulance Authority embraces needed changes in the provision of EMS services.

By Alan E Perry

Why I checked them out

I was intrigued by the Richmond Ambulance Authority (RAA) web presence which is very active in promoting the organization, its providers and EMS public education.  All subjects I like to see EMS systems promote, both for their own well-being and the good of the communities they serve. The web site (http://www.raaems.org/) is well organized and the organization very open about their operations. They pursue a high level of efficiency and hold themselves to high standards for response time and unit utilization using system status management. My interest was such that I inquired about part-time employment to get an inside view of the system, that is still on hold, but I was able to do a ride-along on Medic 483 to see how it all came together on the street. This document is merely my impression of the service based on my own opinions and experiences.

Their unique environment

In March of 1991 the Virginia General Assembly created the Richmond Ambulance Authority for the purpose of providing the City of Richmond with the framework to build a high quality and innovative EMS system. It has been successful; the RAA is accredited by the National Commission on Accreditation of Ambulance Services (CAAS). Their dispatch center is accredited by the National Academy of Emergency Dispatch (NAED), and is one of only eleven EMS systems in the country to possess both. Those of you familiar with these organizations know that obtaining these qualifications is no small task. This illustrates the level of support and singularity of purpose the organization possesses. With this mandate they have developed an entire EMS system focused on efficiency, integration of technology, evidence based treatment protocols and logical operational policies that serve as a model for the provision of EMS anywhere. Richmond has a permanent population of around 200,000 which swells to up to a million on any given work day, their call volume is approximately 60,000 annually.

What seems to work

As an EMS provider I appreciate the seamless functionality of good quality communications and dispatch systems. RAA has its own dispatch center, uses both radio and wireless GPS to locate, dispatch and map units route to calls, units can respond and mark on scene by the push of a button keeping radio channels clear of unnecessary traffic. The GPS system keeps track of all units and facilitates the dispatch of the closest appropriate unit for a call. Software in the dispatch center is predictive of call locations and volume based on historic data allowing units to be stationed in relative proximity to the next expected call keeping response times below 9 minutes. All 911 response units have at least one paramedic on them. All trucks are equipped with power stretchers. Reports are completed on highly functional ePCR software which links wirelessly with their Zoll monitors. Unit inventory is maintained through a sealed bin system, if a bin is opened it is replaced with a new sealed bin, in this way unit inventories are always complete and standardized. RAA appears to have an excellent working relationship with the facilities they serve, the EMS report/break rooms at all facilities are clean and inviting, have well stocked snack boxes and a wide variety of beverages in the refrigerators to keep the providers sustained during their 12-16 hour shifts. RAA has an excellent working relationship with the Richmond Fire Department. Their single facility on Hermitage road houses the administrative offices, dispatch center, training center, supply and equipment warehouse and Ambulance maintenance shop.

Some of the same old problems

Some of the problems remaining are the same that are found in just about every EMS system. There are a large number of non-emergency and nuisance calls, the Police hand off some questionable psychiatric patients, and every call is dispatched as a priority one call until proven otherwise. As a former EMS system manager and Field Officer the issues with unsecured equipment and the general cleanliness of the units and equipment still concern me. Employees suffer from inequality in pay across public safety disciplines frequently working second jobs to make ends meet.

What I would do to improve the system

RAA has an excellent public education and marketing program already in place, this program can be used to address the appropriate use of the 911 system to the general public to reduce the burden of unsubstantiated calls. Build up the value of your employees and attempt to get the compensation more in line with other public safety personnel. The facilities at RAA are already equipped for decon of contaminated equipment, it may be useful to put each unit through a decon process weekly to include thorough cleaning of the box, the cab and all of the equipment on it. Make the VAOEMS regulations part of the training process for all employees to get better compliance with requirements for securing equipment and hygiene. Permit scheduled breaks for crews to eat a meal without having to do so in the cab of the truck, perhaps permitting them to rotate through stations at local ER’s to accomplish this will not disturb the deployment model too much.

Conclusion

RAA has established itself as a proactive, competent and capable resource for the citizens and visitors of Richmond. It is, in my opinion, a shining example of what an EMS system should strive for. RAA has embraced many of the suggestions put forth ten years ago in the EMS Agenda for the Future, an accomplishment for them and an unheeded warning to most other EMS systems in the State and Nation. RAA should be cautious, you can never rest when you are on top, you must take advantage of the position to keep pushing forward. The same CQI process used to evaluate patient care needs to be applied to the entire system. Continued success will require improving operational and patient care efficiency, increasing the value to the community and the providers and building the trust and respect of the public and your employees through continued integrity in your actions.