A very nice report, part of the IHI Patient Safety in the Home initiative.
A full report, with additional case studies can be found in the No Place Like Home: Advancing the Safety of Care in the Home report.
Can Paramedics Help Achieve the Triple Aim?
By IHI Multimedia Team
Friday, August 24, 2018
Background of the Problem
Left unidentified and unaddressed, the medical, social, and patient safety concerns that arise in the home can increase the burden on emergency medical services and emergency departments. In particular, patients with complex medical conditions and/or challenging socioeconomic situations may be more reliant on emergency health care resources because they may face multiple barriers to accessing health care and other services, have unmet medical and social needs, or grapple with unsafe home conditions. Paramedics are proficient in interacting with patients in home settings and can respond quickly when patients need help. Paramedics thus represent an important resource for providing critical support and services to individuals who face safety and health care challenges at home.
Description of the Program
MedStar Mobile Healthcare, an EMS provider in the greater Fort Worth, Texas, area, developed a suite of programs designed to leverage the skills and expertise of paramedics to intervene with high-risk, high-need patients in home settings. These Mobile Integrated Healthcare (MIH) programs aim to ensure that patients receive safe, effective care in the most appropriate setting.
Each of the MIH programs includes these components:
- Processes to identify patients who are eligible for the program.
- In-depth, home-based visits are conducted by specially trained Mobile Healthcare Paramedics (MHPs) to identify patients’ medical, social, behavioral, and safety-related needs.
- Bimonthly care coordination meetings are held in which a MedStar program coordinator confers with hospital caseworkers, community service agencies, and other care providers to review the needs of enrolled patients.
- Alternative services help patients avoid having to call for EMS, including the ability to request a home or telephone visit from an MHP instead of calling 911.
- A continuously updated electronic medical record provides mobile access to information about the patient’s entire course of assessments and treatments while participating in the program.
- Contractual arrangements exist between MedStar and hospitals, commercial insurers, and other health care service organizations to receive payments for the MIH services.
MedStar identifies patients who qualify for its MIH programs using a variety of approaches and data sources:
- MedStar identifies patients for the High Utilizer Program (those who have called 911 at least 15 times in the past 90 days) by analyzing 911 utilization data and receiving referrals from emergency departments, frontline MedStar staff, and other first-responder agencies, as well as agencies and payers partnered with MedStar.
- Participating hospitals and physicians refer patients assessed as being at high risk for readmission within 30 days of discharge to the Readmission Prevention Program.
- Agencies partnered with MedStar refer patients to the Home Health Partnership Program, the Hospice Revocation Avoidance Program, and the Observation Admission Avoidance Program.
After a patient is deemed eligible for one of MedStar’s MIH programs, a specially trained MHP or a representative from a partner organization contacts the patient to explain the benefits of the program. If the patient agrees to participate, the patient signs a consent form authorizing the appropriate parties to share relevant patient information via the electronic medical record system.
The MHP conducts an in-depth, in-home visit with the patient, family members, and caregivers. During the visit, the MHP performs a full medical assessment, evaluates the patient’s home environment and safety-related factors, and identifies opportunities to enroll the patient in other programs to help meet the patient’s clinical, social, or behavioral health needs (e.g., medication compliance, nutritional support, healthy lifestyle changes).
Based on the assessment findings, the MHP works with the patient and family to develop or reinforce an individualized care plan, in coordination with the patient’s primary care network. This plan outlines the patient’s needs, associated goals, and steps needed to reach the goals. The patient and family members receive a copy of the plan, which is entered into the electronic medical record system and thereby is readily accessible to MHPs and other providers.
The patient receives a telephone number to use to request an MHP home or telephone visit as an alternative to calling 911. Because MedStar is the 911 provider in the service area, if the patient calls 911, the MHP is dispatched to the patient’s location, along with the normal EMS system response. Once on scene, the MHP may apply established care protocols to address the patient’s needs, thereby preventing an unnecessary ambulance transport.
The MHP conducts periodic follow-up visits with patients based on their needs. These visits provide an opportunity to evaluate any new medical or safety needs, monitor progress in meeting care plan goals, and provide the patient with additional supports or referrals.
A MedStar MIH program coordinator meets bimonthly with hospital caseworkers, community service agencies, and other care providers to review the needs of patients who are enrolled in the program and to coordinate resources.
Some of MedStar’s MIH programs have a formal “graduation” process for patients whose social and safety needs have been addressed and who can manage their own health care needs.
MedStar’s MIH programs have garnered domestic and international interest as a promising strategy to address the health care and home safety needs of patients with complex medical conditions. MedStar has hosted site visits by representatives of more than 221 communities from 46 states and seven other countries who are interested in learning how the MIH programs work and replicating the MIH model.
Across its portfolio of MIH programs, MedStar has “graduated” more than 8,500 patients. MedStar’s MIH programs have improved the quality of life for enrolled patients and reduced EMS transports to the hospital, ED visits, and hospital admissions, suggesting that the health of these patients is better because their health and safety needs were addressed at home.
Evidence includes the following:
- A retrospective evaluation [Published in the American Journal of Emergency Medicine] assessed pre- and post-intervention data for 64 patients who completed MedStar’s MIH High Utilizer Program. The evaluation showed that:
- Patients who had reported problems with mobility, pain control, and ability to perform activities of daily living before participating in the program reported improvements in these areas (38, 42, and 58 percent, respectively) after participation.
- After participation, 73 percent of patients rated their health as improved.
- Patients had 61 percent fewer EMS transports, 66 percent fewer ED visits, and 56 percent fewer hospital admissions.
- A MedStar report analyzed trends in pre- and post-enrollment utilization data among 581 patients enrolled in the MIH High Utilizer Program between October 2013 and March 2018. The analysis showed that:
- Ambulance transports to the ED were reduced by 5,133 (58 percent), and ED visits and hospital admissions were reduced by 2,395 and 462, respectively.
- The reductions in utilization decreased health care spending by $9.3 million during the evaluation period, for a savings of $16,046 per enrolled patient.
- MedStar found a total expenditure savings of more than $14 million across all MIH programs between June 2012 and March 2018.13 This represents savings of about $3.2 million in ambulance transport, $4.5 million in ED visits, and $6.4 million in hospital admissions.
- Between September 2013 and March 2018, 388 patients identified by a hospice agency as likely to disenroll from hospice were enrolled in MedStar’s Hospice Revocation Avoidance Program. Of those, only 18 percent had a disenrollment.
- The patient experience across MedStar’s MIH programs was favorable, with overall average ratings ranging from 4.69 to 4.84 on a 5-point Likert scale assessing 12 items related to patient experience.
- Between October 2013 and July 2017, 295 patients with a prior 30-day readmission were identified as being at high risk for another 30-day readmission and enrolled in the Readmission Prevention Program. Of those, 47.5 percent had a 30-day readmission, which evaluators considered lower than would have been expected.