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Home Health and EMS-Based
Mobile Integrated Healthcare
Shotgun Wedding
or
A Match Made in Heaven
© 2015 MedStar Mobile Healthcare
What we’re gonna do…
• The “Why”– Analyze the current state of the US Healthcare system
• Special focus on Home Health and Hospice issues
• The “How”– “EMS” and home health/hospice can and are collaborating
• How could that fit in your world?
• And –– Learn certain words that have a whole different meaning
in Texas…
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Summer:• What it means everywhere else: A time for vacation, road
trips, and fun in the sun.
• What it means in Texas: Hell on Earth where the temperatures
rarely dip below 100 degrees.
About MedStar…• Governmental agency (PUM) serving Ft. Worth and 14 Cities
– Self-Operated
– 880,000 residents, 421 Sq. miles
– Exclusive provider - emergency and non emergency
• 117,000 responses annually
• 450 employees
• $37.5 million budget
– No tax subsidy
• Fully deployed system status management
• Medical Control from 14 member Emergency Physician’s
Advisory Board (EPAB)
– Physician Medical Directors from all emergency
departments in service area + 5 Tarrant County Medical
Society reps
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Our World is Changing:
Attention Please!
• $9,255 per capita health expenditures!!
– Due in large part to quantity-based payments
http://kaiserhealthnews.org/news/health-costs-inflation-cms-report/
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Our New Environment:
• Steroid Injection = ACA– ACOs (523 as of April ‘14)
• 368 Medicare
• 155 Commercial Insurer-based
• 31 million covered lives
– Payment based on OUTCOMES
– Bundled payments based on episode of care
– Push to Managed Medicare/Medicaid
– MSPB calculations = 2015• Medicare Spending Per Beneficiary
– Hospital accountable for some outpatient post acute costs
http://www.beckershospitalreview.com/accountable-care-organizations/total-number-of-
acos-tops-520.html
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HHS Pledges To Quicken Pace Toward Quality-Based Medicare PaymentsBy Jordan Rau January 26, 2015
The Obama administration Monday announced a goal of accelerating changes to
Medicare so that within four years, half of the program’s traditional spending will go
to doctors, hospitals and other providers that coordinate their patient care,
stressing quality and frugality.
The announcement by Health and Human Services Secretary Sylvia Burwell is
intended to spur efforts to supplant Medicare’s traditional fee-for-service medicine,
in which doctors, hospitals and other medical providers are paid for each case or
service without regard to how the patient fares. Since the passage of the federal
health law in 2010, the administration has been designing new programs and
underwriting experiments to come up with alternate payment models.
“For the first time we’re actually going to set clear goals and establish a clear
timeline for moving from volume to value in the Medicare system,” Burwell said
http://kaiserhealthnews.org/news/hhs-pledges-to-quicken-pace-toward-
quality-based-medicare-payments/
Truck:
What it means everywhere else: A machine used for hauling heavy
loads.
What it means in Texas: Every other vehicle on the road.
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PCPs are in shortest supply in low-income, low-insured areas, many of which are rural
communities. Several solutions and existing best practices could address these
issues, however:
• Value-based payment models: Payment systems that provide incentives for value
and outcomes over intensity of service "are fundamental to increasing primary care
capacity and improving the effectiveness and efficiency of service delivery," the
report states. This could include performance-based bonuses linked to quality
benchmarks or risk-adjusted monthly payments for primary care.
• Expanded responsibilities for nurse practitioners (NPs) and physician assistants
(PAs): Leveraging non-physician clinicians can help practices expand capacity,
according to the report. This is demonstrated by expanded scope of practice for NPs
and PAs in several states, including New York and Kentucky.
• Multidisciplinary care teams: To further distribute their workload, PCPs must also
expand responsibilities for professionals such as health coaches and medical
assistants. Such multidisciplinary efforts historically improve outcomes and cut
costs, according to the report.
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CMS Bonuses/Penalties…
• Readmissions (up to 3%)– 2013-2014
• MI
• CHF
• Pneumonia
– 2015• COPD
• Hips/Knees
Medicare Fines 2,610 Hospitals In Third Round Of Readmission
PenaltiesBy Jordan Rau
KHN Staff Writer
Oct 2, 2014
Medicare is fining a record number of hospitals – 2,610 – for having too many
patients return within a month for additional treatments, federal records released
Wednesday show. Even though the nation’s readmission rate is dropping,
Medicare’s average fines will be higher, with 39 hospitals receiving the largest
penalty allowed, including the nation’s oldest hospital, Pennsylvania Hospital in
Philadelphia.
Under the new fines, three-quarters of hospitals that are subject to the Hospital
Readmissions Reduction Program are being penalized. That means that from Oct.
1 through next Sept. 30, they will receive lower payments for every Medicare
patient stay — not just for those patients who are readmitted. Over the course of
the year, the fines will total about $428 million, Medicare estimates.
http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-readmissions-penalties-
2015.aspx
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Medicare uses the national readmission rate to help decide
what appropriate rates for each hospital, so to reduce their
fines from previous years or avoid them altogether, hospitals
must not only reduce their readmission rates but do so better
than the industry did overall.
"You have to run as fast as everyone else to just stay even,"
Foster said. Only 129 hospitals that were fined last year
avoided a fine in this new round, the KHN analysis found.
Medicare officials, however, consider the competition good
motivation for hospitals to keep on tackling readmissions and
not to become complacent with their improvements.
http://www.kaiserhealthnews.org/Stories/2014/October/02/Medicare-
readmissions-penalties-2015.aspx
The all-cause 30-day hospital readmission rate among Medicare fee-for-service
beneficiaries plummeted further to approximately 17.5 percent in 2013,
translating into an estimated 150,000 fewer hospital readmissions between
January 2012 and December 2013.
This represents an 8 percent reduction in the Medicare fee-for service all-cause
30-day readmissions rate.
http://innovation.cms.gov/Files/reports/patient-safety-results.pdf
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CMS Bonuses/Penalties…
• Value-Based Purchasing (up to 1.5%)
– Clinical process of care (12)
– Patient experience (8)
– Healthcare outcomes (5)
– Efficiency (1)
Value-Based Purchasing…
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Packing:
What it means everywhere else: Putting stuff away in
preparation of a move.
What it means in Texas: How much firepower you’re
carrying.
EmergencyMedical
Services?
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“EMS?”
• 9-1-1 safety net access for non-emergent
healthcare– 35.6% of 9-1-1 requests
• 12 months Priority 3 calls (44,567 (P3) / 124,925 (Total))
• Reasons people use emergency services– To see if they needed to
– It’s what we’ve taught them to do
– Because their doctors tell them to
– It’s the only option
• 37 million house calls/year– 30% of these patients don’t go with us to the hospital
2012 NASEMSO Report
“EMS?”
Call Type % Increase
Interfacility 11.32%
Sick Person 10.37%
Falls 5.87%
Unc Person 5.20%
Assault 4.21%
Convulsions 4.16%
Psyc. 3.76%
Call Type % Decrease
Abd Pain 2.83%
Traum Inj. 3.71%
Chest Pain 7.97%
MVA 10.38%
Breath. Prob. 10.48%
10-year % change of overall call volume…
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EmergencyMedical
Services?
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UnscheduledMedical
Services!
Our Role?“Emergency medical services (EMS) of the future will be community-
based health management that is fully integrated with the overall
health care system. It will have the ability to identify and modify
illness and injury risks, provide acute illness and injury care and
follow-up, and contribute to the treatment of chronic conditions
and community health monitoring. This new entity will be
developed from redistribution of existing health care resources and
will be integrated with other health care providers and public health
and public safety agencies. It will improve community health and
result in more appropriate use of acute health care resources. EMS
will remain the public’s emergency medical safety net.”
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Football:
What it means everywhere else: A popular American team sport.
What it means in Texas: Religion.
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Current State of Home Health
• Financial Penalties for Readmissions
• Hospitals Today � Home Care in future
• CENSUS AND CARE PLAN INTERRUPTIONS
• Educate the patient Call Your Nurse
•…911 (panicked patients and families)
• EMS Working against Home Care
• Paid for Transports to Hospital
Home Care Desired State –EMS Partnerships
• Incentives congruent with EMS
• Home Care Notified when Patients Calls 911– Integrated EMS/Home Health Intervention
• Home Care Medical Dir. & EMS Medical Dir.– Integrated Protocols and Procedures
– Patient Case Conferences & Shared EMR
• Reduce Hospitalizations & Increased Referrals
• Quality Performance Improvement
• Health Care Savings
• Business Development
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Stars Align…
• Home Health– Reduce unnecessary ED visits
• Increase hospital referrals
– Reduce unnecessary admissions/readmissions• Increase hospital referrals
– Know when patients call 9-1-1
– Bridge from referral to 1st home health visit
– After hours coverage
– Referrals from EMS-MIH providers• When patients qualify
How it Works – Home Health
• Klarus registers patients in MedStar service
area
• Patients entered into 9-1-1 dispatch system
• EMS EMR created with basic information
• Interface login with Kinser for EMS-MIH
providers
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How it Works – Home Health
• If patient calls 9-1-1…
– Ambulance and MHP respond
– Klarus on-call nurse notified of response
– MHP arrives and assesses patient
– Calls Klarus nurse for consult/disposition coordination
– If medical orders, agreed protocols
• Foley, wound vac, diuresis, COPD, hypoglycemia
– Treat and refer, or treat and transport
• If requested by Klarus
– On-scene support and care coordination
How it Works – Home Health
• If other MIH program referral meets home
health enrollment criteria– Klarus preferred provider
• Other relationships � referrals
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Response:Outcome Analysis
Klarus
As of: 3/31/2015
Enrollments 553
Emergency Calls 275 49.7%
Emergency Calls w/o MHP on scene 154
Transports w/o MHP on scene 133 86.4%
Emergency Calls w/MHP on scene 121
Transports w/MHP on scene 47 38.8%
Home Health Data (2/14 – 3/15)
• 92 Visits Requested by Klarus Home Care
– Primarily after hour “Crisis”
– 0 transports
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Klarus Home Care – Case #1• PATIENT SITUATION:
– 68 Year Old Obese Female living in Extended Stay Hotel
– DX DMII uncontrolled
– New Admit, County Hospital Referral, No Dr. of Record, No Sliding Scale Orders
– RN visit in day time BS 500 no distress symptoms, Administered Victoza 1.2 mg
• FOLLOW UP INTERVENTION REQUESTED BY KLARUS RN:– MedStar Advance Paramedic makes a after hours visit to patient
– BS 350, Paramedic consulted with on Call RN
– Paramedic Consulted with EMS Medical Director
– Medical Director advised to increase water input for tonight
– RN follow up next day consulting MedStar
– MedStar used Taxi voucher to transport patient to County Clinic New Orders
• OUTCOME:– Patient not transported to Emergency Room
– Patient safe and BS monitored after hours
– Patient utilized non emergency transport Dr. to obtain New Sliding Scale Orders
Klarus Home Care – Case #2• PATIENT SITUATION:
– 67 Year Old Male, DX: Cardiomyopathy, Chronic Sys Heart Failure, Pleural Effusion, DMII,
– Exacerbation of CHF 2x in last 60 days TX by RN using Klarus CHF Protocols 40 mg IV
Lasix
– Patient calls Ambulance after hours due exacerbation. Does not call Home Health
• FOLLOW UP INTERVENTION REQUESTED BY KLARUS RN:– MedStar Advance Paramedic identifies Patient as Klarus Patient, Calls RN on Call in
Route to House
– Assessment reported to RN: Patient Short of Breath, Legs swollen edema 3+
– RN Advised MedStar to Use CHF protocol & Administer 40 mg IV Lasix
– MedStar verifies CHF orders in Klarus Electronic Medical Record & Consults EMS Medical
Director
– IV Lasix administered
– MedStar provides follow up visit later that night checks potassium, consults on call
physician, and adjust the potassium
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Klarus Home Care – Case #2
• OUTCOME:
– CHF Patient not transported to Emergency Room
– CHF exacerbation signs and symptoms eliminated
– Coordination with Klarus & Use of Protocols prevents unnecessary
Hospitalization
– Health Care Cost Savings $9,203
Client: XXXX, Barry - 1952-XX-XX
Program: Home Health - 911
Status: Active
Referring Source: Klarus
DSRIP Client: No
Visit Date: 11/27/2014 14:02
Visit Type: Home Visit
Visit Acuity: Unscheduled Visit
Visit Outcome: MHP Call Complete
Klarus called for us to go out and check Pt's cath. relayed it was leaking. upon
arriving on scene, Pt relayed pain. wife relayed she had not noticed any leaking.
first the bulb was deflated. 7cc's of fluid pulled out. some urine voided after
deflation from around the cath. Cath was advanced approx 2inches and re-
inflated with 10cc's of fluid. Pt confirmed relief of his pain. Told him to call back
if he started having pain again. The only other option will be to remove the cath.
The urine was dark yellow. No sediment noted.
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EMS/MIH Case Study #1 – Home Health
Client: XXXX, Barry - 1952-XX-XX
Program: Home Health - 911
Status: Active
Referring Source: Klarus
DSRIP Client: No
Visit Date: 11/27/2014 17:45
Visit Type: Home Visit
Visit Acuity: Unscheduled Visit
Visit Outcome: MHP Call Complete
Client called back because he was sWll hurWng. Made scene and
removed cath. No problems removing. he immediately felt
better and relayed no pain again. He urinated into a urinal so
there may have been a blockage in the cath itself. Called and
discussed with Klarus for follow-up visit PRN.
Program: Home Health
Status: Active
Referring Source: Klarus
Visit Date: 11/27/2014
Visit Acuity: Unscheduled Visit
Visit Outcome: MHP Call Complete
Transport Resource: N/A
Note:
Arrived on scene per Klarus request to stop wound vac and place a wet to dry dressing
due to blockage on wound vac. Upon my arrival client met us at the door in good
spirits. She explained her wound vac started with an error message which read
blockage. She did have a blockage in the tubing closest to the pump itself. I clamped the
tubing and turned the vac off then opened the tubing, re-secured the tubing then
unclamped it and turned the pump back on; the blockage immediately cleared. I waited
with the client for about ten minutes to see if the problem was solved. I provided client
with our non-emergency number in the event it occurred again we would then place a
wet to dry dressing. I contacted the after hours number for Klarus and spoke with
Diana. I left all of the material for the wet to dry dressing in the clients home. Visit
Complete. MHanson
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From: MHP Clients [mailto:[email protected]]
Sent: Saturday, April 11, 2015 11:26 AM
To: Monica Cruz; Darla Kemp; Matt Zavadsky; Sherry Willingham; Susan Swagerty
Subject: MIHP Note - Source: Klarus - Program: Home Health - 911
Client: XXXXX, Joycia Y – 19XX-XX-XX
Program: Home Health - 911
Referring Source: Klarus
Visit Date: 4/11/2015
Visit Type: Home Visit
Visit Acuity: 911 Call
AOSTF pt. lying on couch in NAD. Crew reports pt. has been having CP since last night and is
mid sternal and radiates to her back, rates at 9/10. Her pain is worsened by movement and
breathing. Her V/S are reported to be stable and she is reported to be a little anxious. In
speaking with the pt. she agrees with the crews report of the situation. She also reports she
has had a 10lb weight gain since yesterday according to her Cardiocom unit. She has had
this in the past and this is the same pain she usually has. She believes her NTG will relieve it
but she was afraid to take as Klarus usually walks her through it. She also has an anxiety
history and has not taken her Xanax or other morning meds yet. Pt. denies any N/V or
diaphoresis.
She also feels like her hands and feet are swollen as they feel tight. She denies
additional complaint. Upon exam noted pt. in NAD. Pt. is A&OX4, PPTE, MAE.
VSS. BSCB, non labored. SR on 12-lead w/o acute changes. No edema is noted to
hands and very mild edema noted to top of her feet once socks removed. I spoke
with Diana at Klarus regarding this pt. I reported her complaints. I did advise her
about the weight gain. She felt pt. should take her NTG. She also reports pt.
has been to the hospital for this in the past and was ruled Anxiety those times.
Pt. reported dramatic improvement in the discomfort after the NTG. Pt. was
advised we could not R/O cardiac involvement without blood work but pointed
out what we found on exam. Pt. opted to take her morning meds and stay at
home.
As we were getting ready to leave Diana called back and reported her weight
had in fact increased by 10 lbs. over the last 24 hours and would like her to be
diuresed. I relayed this to the pt. and she agrees to plan.
A Chem 8 was obtained and her K+, Hct and Hgb was noted to be low.
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I spoke with Dr. Davis regarding the Potassium dosing since she was a little low
and he advises to increase her Potassium from 40 mEq Bid to 40mEq Tid today
only.
IV was initiated and Lasix 100mg IV was given SIVP. Pt. was advised to
monitor and record her urine output using the hat she was provided and we
would see her at 1400 for a F/U. If anything changes to call Klarus or us back.
Pt. remains pain free upon departure.
I again spoke with Diana and advised of the treatment and that she would
need a visit from them within 24 hrs. by protocol and she was going to get that
set up. Visit complete.
Austin:
What it means everywhere else: The capital of Texas.
What it means in Texas: A completely different planet.
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Hospice Referral
• Trusted hospital partner refers hospice eligible patient
• Commitment to response made
Evaluation & Admission
• Patient appropriate for care
• Admission completed/family educated but remain anxious
Revocation
• Significant change in condition
• Family panics and calls 911
• First Responder returns patient to trusted hospital partner ER
• Readmission to trusted hospital partner ER
• EMS charge of $800
• ER Charge of $3500
• Decreased Revenue of $7104
Loss of
• Census
• Revenue
• Trusted
Hospital
Partner
Mobile Integrated Healthcare
Hospice Referral
Evaluation And Admission
Family Anxious/Calls 911
• Retention of ADC
• Increased Family
Satisfaction
• Increased FEHC
Score
• Less expenses
• No loss of Revenue
• Increased Trust
with Hospital
Partner
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Stars Align…
• Hospice
– Prevent unnecessary ambulance transports
– Prevent unnecessary ED visits
– Prevent unnecessary acute care admissions
– Prevent voluntary disenrollments
– Prevent revocations
Framing the Hospice Issue:
• Patients & families want patients to die
comfortably at home
• Hospice wants the patient to die at home
• Death is scary
• When death is near….
• 9-1-1 usually = Hospice Revocation
– Voluntary or involuntary
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Economic Model
• Hospice benefit– Per diem from payer to agency
– Agency pays hospice related care
– LOS issues
– Varies based on Dx
• MedPAC recommends increasing hospice
benefit
• IHI recommends increase hospice enrollment
How it Works - Hospice
• Patients/Families ID’d by VITAS as ‘at-risk’ for
9-1-1 call
• Referred to MedStar program
– Entered into 9-1-1 system
• Joint initial home visit with hospice RN &
MedStar
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How it Works - Hospice
• In case of 9-1-1 call
– MHP co-responds with ambulance
– Comm Center calls on hospice RN while enroute
Ambulance and MHP arrive
– If call not related to hospice plan of care
• Handle as usual
How it Works - Hospice
• If is part of plan of care
– Calm and reassure family
– Make patient comfortable
• Access prescribed comfort pack
– Assess and call hospice nurse
– Determine disposition
• Await RN
• Release ambulance
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How it Works - Hospice
– If ‘really bad’
• Arrange for in-patient hospice transfer
• Referrals from other programs (CHF)
– Stage 4 CHF
– Conversation project
– Refer to VITAS after family agrees to palliative care
Hospice Program SummarySept. 2013 - March 2015
# %
Referrals (1) 209
Enrolled (2) 176
Deceased 133 75.6%
Active 21 11.9%
Improved 2 1.1%
Revoked (3) 20 11.4%
Activity:
EMS Calls 55
Transports 34
ED visits 27
Direct Admits 7
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EMS/MIH Case Study #1 – Hospice
XXXXXX, Sybil W 89 Years (Actual) Female 126 Lbs Ethnicity: Caucasian
Chief Complaint: Breathing Problem (Medical);
Working Diagnosis: VITAS Client
COMMENTS
VITAS Hospice Client - 911 call
Dispatched on p1 breathing difficulty. Arrived on scene to find 89 YO WF home
alone. Client relates she became anxious and short of breath. Client relates she is
unable to move from chair to turn on her oxygen on her own. Client appears to
be weak with limited mobility due to her advanced Parkinson's. Client's
paperwork for VITAS is laid out on the table with her signed DNR. Client relates
she has around the clock care with providers provided to her by her family. She
lives with her son and his spouse but they leave Saturday mornings and are not
generally back till the afternoon. Client relates her caregiver is off for today and
she is supposed to have a substitute arrive at 11 am but they are late.
EMS/MIH Case Study #1 – Hospice
I spoke with Helen, the triage nurse with VITAS and discussed the situation with
her. The client is on her oxygen and relates prior to my arrival she took
something for her spasms but was unable to determine what it was she took.
Client relates she feels much better now that she has her oxygen on. I waited for
caregiver to arrive and explained the situation. The caregiver wrote me a note
stating 'she thinks she is short of breath but she really isn't'. I explained it could
very well be anxiety, but having the oxygen on improved her saturation.
She stated she understood. She also spoke with Helen the triage nurse. Ms. XXXX
relays to me she is fine now that Kate, the families friend who is her caregiver, is
there. I left our number with Kate and made sure
Ms. XXXX had her med alert necklace on. Visit Complete. MHanson
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EMS/MIH Case Study #2 - Hospice
XXXX, Ernest J 81 Years Male 303 Lbs Ethnicity: African-American
Chief Complaint: CHP Visit;
Working Diagnosis: CHP Visit
COMMENTS
Arrived on scene I found crew about to move the patient onto the stretcher. I
requested they wait until I could call Vitas and discuss the case with them.
I then spoke to the family and let them know we were going to contact Vitas and
discuss the patient with them. I also asked them about why they had called 911.
Daughter reports the patient was seen today by a physician and was told he had
decreased urinary output and should be seen for that. She decided to call 911 to
send the patient to the hospital to be evaluated for possible dialysis.
EMS/MIH Case Study #2 - Hospice
I spoke to Vitas and advised them we were on scene. I also told
them the patient's family agreed to wait until the nurse to arrive
to decide on transport, so they dispatched a nurse. I released the
ambulance at that point.
I waited on scene until the nurse arrived. I turned care over to
her and gave a basic report regarding why we had been called,
along with vital signs. She then evaluated the patient and spoke
with the family. The decision was made to treat the patient at
home. I then cleared the scene.
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EMS - Current State
• Reactive vs. proactive
• “You call, we haul, that’s all”
• Paid only to transport
– Only eligible destination is ED
– When all you have is a hammer….
• Limited integration of the healthcare system
• “Pre-Hospital” care
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• Right Resource
• Right Time
• Right Patient
• Right Outcome
• Right Cost
EMS - Desired StateMobile Integrated Healthcare
EMS-MIH/Home Health &
Hospice Partnerships
• Fill gaps– Refer to enroll gap
– Night/weekend call
– Patient’s not eligible for home health
• Cooperate, not compete– 9-1-1 collaboration
• Very different delivery models
• Align incentives
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EMS-MIH/Home Health &
Hospice Partnerships
• Other EMS-MIH Services– 9-1-1 Nurse Triage
– High Utilizer Programs
– Readmission prevention programs
– Ambulance transport alternative destinations
– NP/PA ambulances
• 260 programs nationwide– And growing
• 6 CMS HCIA Grants– ~$40 million from CMS to test model
NAEMT Survey
• 125 active EMS/MIH programs in U.S.
– 102 responses to this question…..
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EMS-MIH/Home Health &
Hospice Partnerships
• Fill gaps– Refer to enroll gap
– Night/weekend call
– Patient’s not eligible for home health
• Cooperate, not compete– 9-1-1 collaboration
• Very different delivery models
• Align incentives
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“Mobile Integrated Healthcare is an
innovative and patient-centered approach
to meeting the needs of patients and their
families. The model does require you to
“flip” your thinking about almost everything
– from roles for health care providers, to
what an EMT or paramedic might do to care
for a patient in their home, to how we will
get paid for care in the future.
The authors teach us how to flip our thinking
about using home visits to assess safety and
health. They encourage us to segment
patients and design new ways to relate to
and support these patients. And they urge
us to use all of the assets in a community to
get to better care. This is our shared
professional challenge, and it will take new
models, new relationships, and new skills.”
Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
Texas:
What it means everywhere else: A place full of rodeos, boots,
horses, and cowboys.
What it means in Texas: Home, and the only place that matters.
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