Tomorrow’s Provider: EMS Emergency transport? Yes. In-home care and monitoring? That too.


Used to be, emergency medical services, or EMS, was primarily a mode of transporting critically ill or injured people to the hospital in a hurry. That’s still a key part of its mission. But today, with advanced technology, greater capabilities of emergency medical technicians and paramedics, and the overarching need to improve care while lowering costs, EMS is increasingly being viewed as part of the care continuum.

In fact, through an initiative called integrated mobile healthcare or community paramedicine (IMH/CP), EMS professionals may find themselves spending more time in the community, supporting post-discharged patients and homebound people with chronic illnesses.

The EMS professional
Today’s EMS professionals are up to the task, according to those with whom Repertoire spoke.

“EMS providers have become increasingly proficient over the past decade performing many procedures unheard of decades ago, such as rapid sequence induction, intubation, intraosseous infusions and pericardiocentesis,” says Debra Perina, M.D., MS FACEP, FAEMS, division director, prehospital care, University of Virginia, and a board member of the American College of Emergency Physicians. “They are much more adept at critical thinking and resuscitation, of both trauma and cardiac patients, from continual education programs and quality improvement program feedback. Physicians have come to rely on paramedic assessment to mobilize trauma, STEMI [ST-Elevation Myocardial Infarction], and stroke teams, as well as to begin proper treatment during transport.”

Says Jonathan Washko, MBA, NREMT-P, AEMD, assistant vice president, Center for EMS, Northwell Health (and a board member of the National Association of Emergency Medical Technicians), “In the past five years, EMS has transitioned from a transportation commodity to a recognized clinical provider, able to deliver healthcare services in the out-of-hospital environment. We are seeing EMS providers entering the industry with associate, bachelor’s and master’s degrees.” More females and minorities are entering the industry as well, he adds.

EMS professionals have kept pace with the latest breakthroughs in life-saving medications, says Washko. As technology has improved (and shrunk in size), they are able to perform point-of-care lab testing, ultrasound and other procedures, and they communicate with hospital-based caregivers via telemedicine and video conferencing.

Most likely, the EMS profession will eventually move from a certificate licensure to a full degree, notes Christine Ford, senior market manager, EMS/Fire, Moore Medical, an affiliate of McKesson Medical-Surgical.

Today’s EMS professional “is more familiar with new, advanced technologies now available in prehospital care, or more open to learning about them,” she says. Those include:
• Mobile blood analyzers, which can deliver lab-quality results in minutes.
• Handheld ultrasound units, which can be used to detect heart action and validate continued resuscitation, as well as pinpoint location of internal hemorrhages and cerebral blockages, and to share those images – with Wi-Fi and DICOM capabilities – with the hospital.
• Video laryngoscopy, enabling high intubation success for difficult airways, with recording capabilities and Wi-Fi.

“Expect revised definitions of the EMS Scope of Practice Model (SoPM), with evidence that supports improved patient outcomes with the use of new skills and interventions,” continues Ford. “These include therapies such as hypothermia in cardiac arrest, naloxone administration options, and hemorrhage control.” Other potential advances may include:
• Upgraded seating options in ambulances for improved safety and patient access, as Moore Medical is seeing in European emergency vehicles.
• Continued changes in immobilization protocols, including increased use of vacuum mattresses versus backboards.
• Increased use of mechanical CPR systems
• Advanced procedures similar to what Moore Medical is starting to see in European prehospital care, including therapeutic hypothermia (body cooling) treatment and use of body pressure, ECMO (extracorporeal membrane oxygenation) and REBOA (resuscitative endovascular balloon occlusion) of the aorta.

Community paramedicine
“One change that we’ve seen in the last 10 years is the growth of community paramedicine or mobile integrated healthcare,” says Ford. “This permits paramedics and EMTs [emergency medical technicians] to operate in expanded roles to provide more routine healthcare services within their community. This role helps keep patients from returning to the hospital unnecessarily, resulting in reduced overall healthcare costs and hospital readmission penalties for chronically ill patients.

“In the next five years, as more pilot project data becomes available and agencies determine the best models that will work for their communities, community paramedicine programs will continue to develop,” says Ford, who participates in a community paramedicine task force of the National Association of State EMS Officials. “As the cost of healthcare services continues to rise and hospitals seek options to reduce their readmission penalties, the economics of these programs should become more and more practical. For agencies and regions that do not currently have a mobile integrated healthcare program in place, many report that they are currently discussing these models for future implementation.

“In addition to community paramedicine, we expect to see more specialized mobile transport units such as bariatric, NICU and critical care ambulances.”

In 2016, the Mobile Integrated Healthcare/Community Paramedicine Task Force of the American College of Emergency Physicians issued an Information Paper on the topic. “ACEP has long been interested in EMS practice, and MIH/CP is one facet of EMS care,” says Perina.

Several years ago, the association felt a need to inform its members about trends in mobile integrated healthcare and community paramedicine, and how emergency physicians should expect to interact with these programs, says Perina, who chaired a task force on the issue. “Our charge was to help our members understand the impact and what they should expect in practice.”

In its Information Paper, ACEP defines MIH/CP as “a term applied to a new model of community-based healthcare service delivery that often primarily uses emergency medical services (EMS) personnel and systems to provide acute medical care, coordination of services, healthcare maintenance, post-acute care, and prevention services to patients outside of routine EMS transport service to hospital destination care.”

“MIH/CP is the natural next step for evolution of paramedicine as a profession,” says Perina. Initially targeted at rural communities, the concept has expanded, so that at least one program exists in the majority of states, she says. Driving that growth is today’s emphasis on prevention of illness and the need for cost-savings.

“These programs are only a couple of years old, and as such, only a few have reported results. What little data is out there appears to show value, but additional results of such programs need to be analyzed. I think that as these programs grow, EMS will take on even more roles as the interface between patients and the healthcare system.”

And EMS professionals are likely to embrace the opportunity. “It creates a career ladder for medics, and a way to continue growth in the profession,” says Perina.

Career ladder
Mobile integrated healthcare, or community paramedicine, does call for an entirely different skill set than responding to 9-1-1 calls, says Perina. That might call for anywhere from 18 months to two years additional training, including precepting with a physician. “But it allows the medic to grow in paramedicine, and it provides them an additional opportunity to provide direct patient care in the home.”

Veteran EMS professionals who may be on the verge of burning out may find community paramedicine a suitable alternative to 9-1-1 response, Perina continues. “Working in a high-volume, large urban emergency system is really a young man’s game, because of the stress and physical activity,” she says. Still, challenges remain for MIH/CP programs, including:
• State regulations. In some states, regulations prohibit EMS practice outside of traditional 9-1-1 response, or care that is designed to stabilize patients for transport to a healthcare facility. (With current reimbursement requirements, if the patient is not brought to a hospital, the ambulance service is not reimbursed.)
• Funding. Most pilot programs are financed with grants or short-term funds. A more stable source of funding is needed.
• Training. Time and money are needed to create and operate training programs for community paramedicine.
• Evidence. The results of pilot projects need to be gathered to document outcomes and cost-savings.

For more information:
“Mobile Integrated Healthcare/Community Paramedicine Primer, American College of Emergency Physicians, 2016, https://www.acep.org/search.aspx?searchtext=MIH/CP

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Who’s who in EMS?
EMTs, or emergency medical technicians, usually complete a course that is about 120-150 hours in length. EMTs are educated in many skills, including CPR, giving patients oxygen, administering glucose for diabetics, and helping others with treatments for asthma attacks or allergic reactions. With few exceptions, such as in the case of auto-injectors for allergic reactions, EMTs are not allowed to provide treatments that require breaking the skin.

Paramedics are advanced providers of emergency medical care and are highly educated in topics such as anatomy and physiology, cardiology, medications, and medical procedures. Paramedic courses can be between 1,200 to 1,800 hours. They build on their EMT education and learn more skills, such as administering medications, starting intravenous lines, providing advanced airway management, and learning to resuscitate and support patients with significant problems, such as heart attacks and traumas. Paramedic education programs may last six to 12 months.
Source: UCLA Center for Prehospital Care

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EMS Q&A
Repertoire thanks Christine Ford, senior market manager, EMS/Fire, Moore Medical, for answering the following questions.
Q: Who typically mans EMS vehicles?
A: The personnel manning EMS vehicles depends largely on the type of service the agencies provide. For those providing non-emergency transport service, you may see an ambulance attendant, or CPR Ambulance Driver (trained in cardiopulmonary resuscitation). For agencies that offer BLS (Basic Life Support) services, the vehicles are typically manned by emergency medical technicians (EMTs), usually two per vehicle. ALS (Advanced Life Support) service agencies add a paramedic onboard to assist with more complex procedures, depending on the nature of the emergency call. In some regions, the paramedic may drive a separate vehicle – a First Response Chase Vehicle – which follows the ambulance.

Q: How are EMS services reimbursed?
A: The Affordable Care Act provided more access to patients who may have previously been uninsured. Even though reimbursement rates in most states don’t cover the actual cost of transporting a patient to a hospital, a little is better than nothing. As part of the healthcare reform act, the consumer price index (CPI) and ambulance inflation factor (AIF) was adjusted downward for EMS when it was grouped in with private, nonfarm business multifactor productivity (MFP). The Regional/National Fee Schedule also expired in 2009, so that all EMS providers now receive the same reimbursement formula, except for the Geographic Practice Cost index (GPCI) and urban versus rural adjustments. Each year, Congress reapproves the Medicare base rate modifier, which defines increases in the fee schedule for ambulance transport in rural and super rural states. These variances are driven by population. In the future, there is talk about reimbursement being more closely tied to qualitative patient care, but reimbursement models in EMS have been slow to change.

Q: Who makes purchasing decisions regarding EMS products, equipment and services?
A: The emergency medical service field is largely driven by protocols. These protocols can vary by state, as well as specific regions within a given state. Protocol changes usually occur at the level of a medical director. As field technology options advance in prehospital care, the role of the medical director has increased. Many protocols spell out a general type of device or pharmaceutical product that should be used in various scenarios. In these cases, an EMS chief or operations director often decides which option their crew will use. When substitute products are introduced, the training of the crew needs to be considered to ensure quality patient care. After standards have been set for the agency or region, a purchasing director, EMS supervisor, operations staff or supply personnel may handle day-to-day purchases.

Q: Has consolidation affected the EMS market?
A: The emergency medical service industry is highly fragmented, with hospital-based services representing only one of the many different models one will find throughout the country. [That said], consolidation has also continued in the EMS industry, with larger private ambulance services/agencies joining up with smaller services. Expect to see this trend continue, with smaller agencies or municipalities contracting out their ALS or BLS transport needs, and larger private agencies purchasing smaller private agencies for improved economies of scale.

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Health systems and EMS
Given today’s emphasis on the continuum of care and value-based reimbursement, it’s no surprise that EMS and health systems are growing closer.

“Many hospitals have partnered with emergency medical service agencies to provide mobile integrated healthcare services targeted at chronically ill patients and ‘frequent fliers,’ who overuse traditional EMS services,” says Christine Ford, senior market manager, EMS/Fire, Moore Medical. “The hospitals are largely interested in these models in an effort to help reduce their readmission penalties.

“We also see a lot of collaboration for mass casualty training between hospitals and EMS agencies,” she adds.

Says Jonathan Washko, MBA, NREMT-P, AEMD, assistant vice president, Center for EMS, Northwell Health (and a board member of the National Association of Emergency Medical Technicians), “As healthcare consolidates and becomes integrated across the spectrum of services, EMS can be an extremely beneficial tool in the healthcare arsenal, especially in hub-and-spoke models of care or when coupled with population management efforts. Some healthcare systems are recognizing this and are either getting into the ground and air EMS business or are expanding existing services.”

But hospitals’ participation in EMS is dependent on size and funding, he adds. “If the hospital is not part of a larger healthcare system or it cannot derive value from EMS in its marketplace, we are seeing some hospitals shed EMS services, especially in markets where the EMS agency operates in the red and the parent hospital can no longer afford to subsidize their EMS efforts.”
Debra Perina, M.D., MS FACEP, FAEMS, division director, prehospital care, University of Virginia, and a board member of the American College of Emergency Physicians, says that hospital systems’ participation in mobile integrated healthcare services or community paramedicine varies. “Some are partnering in various outreach programs or in accountable care organizations,” she says. “Some target frequent utilizers who may need more in-home contact, and others chronic disease management to prevent multiple visits. Some are using them for specific services, such as injury prevention efforts and home inspections.”

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EMS 3.0
EMS 3.0 is an EMS industry initiative to help EMS agencies and practitioners understand the changes that are needed in EMS to fully support the transformation of the nation’s healthcare system, and to provide tools and resources to help them implement these changes. Following are some basic tenets of the initiative, from the National Association of Emergency Medical Technicians, or NAEMT.
• America’s healthcare system is broken and needs fixing. The best way to fix it is by changing the way care is delivered and coordinated across all spectrums of healthcare providers and facilities.
• EMS must be a part of the solution.
• Today, EMS operates in communities across the country as a trusted and expected medical provider. EMS providers administer care in homes and throughout the community, delivering rapid and reliable medical assessment, care and transportation.
• Many of the patients to whom EMS provides care are not in need of emergent medical interventions, but rather have medical needs that can be better addressed through actions other than transporting these patients to an emergency department. Some examples of these actions can include care coordination, community resource acquisition, and facilitation of transportation to appropriate healthcare facilities.
• EMS is transforming to fill needs in the healthcare system that improve patient outcomes and satisfaction while also providing additional value to the healthcare system. EMS has demonstrated that it can assess, treat, and navigate patients to the most appropriate and convenient location for their medical needs. This may mean that patients receive their treatment in locations other than a hospital emergency department, including in their own home.
• Transformed EMS agencies have proven significant savings in healthcare costs, while also improving the quality of care.

Source: National Association of Emergency Medical Technicians, http://www.naemt.org/docs/default-source/advocacy-documents/ems-transformation/what-is-ems-3-talking-points-final.pdf?sfvrsn=0

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