Excellence in EMS Integration Awards

Montgomery County Adult Protective Services (APS) and Montgomery County Fire and Rescue Services (MCFRS) have launched an innovative partnership to address the most vulnerable among our population. MCFRS is the highest single referrer of cases to APS annually. Patients referred to APS often have a variety of social and medical issues that lead to them calling 911 more frequently than an average resident. Previously, APS case managers would respond to these referrals on their own, but there was limited information flow between EMS and APS regarding case resolution or client needs. To increase the effectiveness of APS referrals, and better address the needs of high utilizers, the Mobile Integrated Health program was started within MCFRS in 2015. MIH partnered with APS and other sections of the Montgomery County Department of Health and Human Services to track EMS high utilizers and identify whether or not they were already receiving county interventions. In many cases, their case managers were unaware of how many 911 calls these clients were generating. Beginning in 2019, the partnership was taken one step further, and a Registered Nurse and Social Worker were added to the MIH team. Both of these positions are also part of the APS program. This cross-training has created a seamless collaboration in which APS and MIH field evaluations can occur simultaneously. The MIH/APS staff can address the needs of appropriate EMS high utilizers by identifying necessary interventions/resources, connecting them to community partners/programs, and diverting 911 calls that would otherwise be generated. These two staff positions also assist in the oversight of the community paramedics who regularly visit EMS high utilizers. Our partnership with APS has also enabled us to share educational information with our providers regarding appropriate APS referrals. In years past, EMS would make referrals but APS was unable to connect with the referring provider due to lack of contact information, misunderstanding of shift rotation, etc. Without a detailed conversation with the provider, APS would not necessarily be able to start an investigation. Once EMS and APS were able to collaborate on these referrals, APS had a consistent connection point which resulted in more APS assessments being performed when needed. MCFRS is proud to say that due to our improved communication and information sharing, 100% of all Fire/Rescue referred cases are deemed to be APS-appropriate and result in an investigation. Lastly, we are working together to explore the introduction of an assessment tool which would be embedded in ImageTrend eMeds report and would allow any clinician to do an immediate and rapid assessment for APS eligibility based on Maryland and Montgomery County criteria. That referral would then be tracked to ensure the clinician followed up directly with APS.

Organization Description
Adult Protective Services (APS) is a program that serves adults, 18 and over, who are in a situation of vulnerability and either at risk of, or experiencing, exploitation and harm.  They investigate situations of suspected abuse and provide professional services designed to protect the wellbeing of vulnerable adults. There are a variety of types of abuse and neglect that warrant a report being made to Adult Protective Services, and an APS intake worker will assess each situation and determine if it necessitates intervention by APS.

Date of Implementation
Original program was implemented in 2015. Program enhancements and cross-staffing began in earnest in November 2019

Number and Demographics of Patients
In FY20, APS received 4,955 referrals. Out of those, 971 were converted into investigations, for an investigation rate of 19.5%. In that same timeframe, MCFRS made 51 referrals to APS, and all 51 became investigations, for an investigation rate of 100%. MCFRS referrals accounted for 5% of all APS investigations in FY20.

Outcomes / Utilization
MCFRS MIH and APS now work collaboratively to address the needs of clients. We provide background information for APS caseworkers on their investigations, such as frequency of 911 calls to the client's home, or medical/hospitalization records through CRISP (Chesapeake Regional Information System for our Patients), a state-wide HIE sharing hospitalizations, EMS encounters, private practice visits, and prescription information.  Our cross-trained staff can simultaneously assess patients for APS and MIH enrollment, and refer patients to appropriate resources quickly and efficiently. They will also be incorporated in future revisions to our Mobile Crisis Response program, Crisis Now.

Supporting Docs
https://results4america.org/tools/case-study-montgomery-county/

2019 AIMHI EMS Integration Award
John Peter Smith Health Network

John Peter Smith Health Network partnered with MedStar Mobile Healthcare on a comprehensive approach to helping improve patient outcomes, enhance experience of care, and reduce healthcare expenditures for high utilizer patients and patients at risk for preventable readmissions. Since initiation of the program in 2013, 507 patients have graduated from the program.

The high-utilizer cohort experienced a 40.6% reduction in ED visits (507 less occurrences) and a 31.3% reduction in inpatient admissions (365 less occurrences). The readmission prevention cohort experienced an 83% reduction in expected readmissions (292 fewer occurrences).

About John Peter Smith Health Network

For more than 100 years, JPS Health Network has served the medical needs of Tarrant County families as the community’s public healthcare system. 

The Network operates the 573-bed John Peter Smith Hospital, providing emergency services and trauma care at Tarrant County’s only Level 1 Trauma Center. JPS operates more than 40 community and school-based health centers in the neighborhoods where our patients live. 

JPS has become a leading academic teaching hospital in innovative curricula, excellence in scholarly activity and evidence-based community-oriented research. Training is important to the mission of JPS in its efforts to meet the health care needs of Tarrant County. 

JPS Health Network is a $950 million, tax-supported health care system for Tarrant County in North Texas. 

JPS is anchored by John Peter Smith Hospital, which is a 573-bed acute care in Fort Worth, Texas. JPS has the only Level 1 Trauma Center in Tarrant County and the county’s only psychiatric emergency services site. JPS is also a certified Chest Pain Center, Certified Primary Stroke Center and an Accredited American College of Surgery Cancer Center. JPS has a Level lll Neonatal Intensive Care Center (NICU).  The network has more than one million patient encounters per year.

Number and Demographics of Patients

168 high utilizer patients and 339 readmission risk patients.

Outcomes

This program has saved estimated healthcare expenditures of $9 million in prevented ED visits and inpatient admissions.

2019 AIMHI EMS Innovation Award
Northern Nye County Hospital District

In April 2018, the Northern Nye County Hospital District entered into a professional services agreement with REMSA's Integrated Health Community Paramedic Program.  With the closure of it's only hospital in Tonopah Nevada, and a struggling EMS Volunteer system the Hospital District sought out services to provide a higher level of care to the citizens and visitors to Northern Nye Co. and specifically, the frontier town of Tonopah NV.     

Through innovation and collaboration, the Hospital District worked with REMSA to develop a program that would supplement the existing Nye Co. BLS Volunteer EMS system by co-responding an advanced life support Community Paramedic to all 911 requests for service.  The Community Paramedic can determine the most appropriate patient pathway including; attending to the advanced life support patient in the back of the Nye Co. Volunteer Ambulance during the approximate 2 hr. transport to the closest receiving hospital, initiating direct communication with an air medical resource, or initiating alternative destination transport to the local clinic for low acuity patients.  Additionally, the Community Paramedic operates under an expanded scope of practice, and has integrated into the local clinic with the ability to assist with treatment, and do telemedicine presentations to the trauma center approximately 4hrs. away in Reno NV.  In mid 2019, the program will begin a mobile telemedicine program during times of non clinic availability.  The program also provides in home Community Paramedic patient referral visits and consultation for numerous cases such as CHF, COPD, and medication compliance.  For non emergency services, The Northern Nye Co. Hospital District established 24/7 access to REMSA's dedicated Nurse Health Line number for medical assistance to residents within Northern Nye Co.     

The Northern Nye County Hospital District has been the driving force behind the program.  The goal of expanding the level of care, determining the most appropriate patient pathway, and eliminating long distance transports for those with low acuity emergencies, has proven to invigorate a depleted volunteer EMS System tired of 4 hour transports.  The dedication and willingness of the Northern Nye Co. Hospital District to apply innovation is truly improving emergency and non emergency healthcare to a frontier area struggling to keep their communities healthy and safe.  The nomination of the Northern Nye County Hospital District is truly deserved, and may ultimately pave the way for rural healthcare throughout the country.

About Northern Nye County Hospital District

The Northern Nye County Hospital District was established by the Board of Nye County Commissioners in May 2015 under the provisions of state law NRS 450.550 and including NRS 450.760 through Nye County Resolution No. 2015-17.   

The purpose of the District is to facilitate the provision of accessible health care services to the residents of and visitors to Northern Nye County. The Board of Trustees recognizes that the delivery of health care services is a dynamic process, and the District must utilize its limited available financial resources in the best and most efficient manner possible.

Date of Implementation

• 1/1/18 Nurse Health Line
• 4/16/18 Community Paramedic Program implemented

Number and Demographics of Patients

Since the launch of Community Paramedics on April 16, 2018 to December 31, 2018 the program has remained in service 24 hours per day 7 days a week without interruption.  There has been no out of service hours documented by REMSA’s Community Paramedics.   

Additionally, REMSA’s Community Paramedics have served as the 2nd ambulance provider for Nye Co. EMS in Tonopah approximately 80% of the time.    

• Responses—282 
• Clinic Assist Responses—19 
• Hospital Transports—106 
• Nurse Healthline Calls—310   
• Transport percentage—42% 
• Non-transport percentage—49% 
• Alternative Destination transport percentage—9% 
• Community Paramedic home referral program—1 currently enrolled for COPD   

Patients have benefited, and survivability rates have improved from the increased level of service and advanced life support practice that has become a normal response to all requests for service within Northern Nye Co. and the surrounding areas.

2019 AIMHI Excellence in Public Information or Education
Pinellas County 9-1-1

Prevent the Fall, Prevent the Call is the title of Pinellas County’s fall prevention program that was implemented beginning in August 2017.

Falls compose the second largest number of medical calls to 9-1-1 and Pinellas County’s EMS system. 86 of the highest 100 users of Pinellas County’s systems are nursing homes, assisted living facilities, and rehabilitation centers. 

In two pilot programs with assisted living facilities, Pinallas County 9-1-1 reduced overall calls for service by 12%–14% in both facilities.  The County reduced falls by 8% and 12% by working with the Facility Directors as well as nursing and care staff along with the residents. The program included a play called "Denying Gravity" and specific training programs for all staff members.  The County now have expanded this to Largo Fire, St Petersburg Fire, and Pinellas Park Fire, and are working to add more fire departments to the program.  Pinellas has found that the program has reduced 9-1-1 calls and helps to manage the county’s EMS growth through education and understanding, as many facilities had no idea the impact their organization had on Pinellas County’s EMS system.  Pinellas County also trained the facilities on how to properly call 9-1-1 for an emergency, which proved to be a very effective way to share what is needed from a caller and they understand why telecommunicators ask many questions.

About the Pinellas County Regional 9-1-1 Center

Pinellas County Regional 9-1-1 Center receives and dispatches calls for all Fire Departments in Pinellas County as well as answering calls for non-emergency calls for the Sheriff's office.  The County received 753,000 calls to 9-1-1 and dispatched 202,000 calls for service.  The County provide public education to thousands of citizens throughout the year from young children to Pinellas County’s senior population.  They offer cellphone training on how to access 9-1-1 through the Pinellas County’s cellphone simulator.

Budget

The County has a public educator in-house who coordinated the entire program at no extra cost.  The Fire Departments provided staff for the trainings and the volunteer group SAGES provided the play, which kept expenditures to a minimum. Pinellas County 9-1-1 utilized current staff to produce and promote this program.

Estimated Reach

The County reached 556 residents in one facility and reduced calls by 14%.  In the other facility, the County reached 400 residents and reduced calls by 12%.  Overall, the program reached thousands through the play, training, outreach during open houses at Fire Departments, and now increased facility participation.  Pinellas is working with 24 facilities at present and looks forward to adding more to the list.  The County provide stats by Pinellas County’s, day, day of week and call type to each facility in the program with so they understand the impact their improvements is having.  Pinellas is excited to reduce falls as well as calls for service to 9-1-1 and EMS.

What's Next

Pinellas is looking to reduce calls from each facility by 10% and falls within that facility by 10%.  The County feel with the pilot program success and each fire department now working to manage EMS growth through education and information, Pinellas County 9-1-1 will help County residents reduce falls and injuries.  The County has seen the program drive results, and now is working to facilitate the growth of the program. 

The Denying Gravity play, created for seniors by seniors, is being offered a number of times this year, with the goal of getting Pinellas County’s residents to take falls seriously. Each ambulance the County puts on the street costs $1.2 million, so reducing falls by 10% overall could result in savings to Pinellas County’s taxpayers as well as free up Fire and EMS resources to be available for other emergencies. This would be a potentially lifesaving outcome that would result in a faster response to true emergencies.

2019 AIMHI Excellence in Value Demonstration or Research
Northwell Health House Calls

Northwell Health House Calls is an Advanced Illness Management (AIM) program that is a top performing CMMI demonstration project that manages an Advanced Illness population composed of the top 5% CMS utilizers that represent 50% of healthcare expenditures. Results were published in two separate scientific journals, the Journal of the American Geriatrics Society and BMJ Supportive & Palliative Care.

Description of Data & Methods

Various peer reviewed journal articles using data collected across the care continuum (IAH, EMS, EHR).  Two separate studies performed and published in two different journals.

Abstract from the Journal of the American Geriatrics Society (JAGS)

Models addressing urgent clinical needs for older adults with multiple advanced chronic conditions are lacking. This observational study describes a Community Paramedicine (CP) model for treatment of acute medical conditions within an Advanced Illness Management (AIM) program, and compares its effect on emergency department (ED) use and subsequent hospitalization with that of traditional emergency medical services (EMS). Community paramedics were trained to evaluate and, with telemedicine-enhanced physician guidance, treat acute illnesses in individuals' homes. They were also able to transport to the ED if needed. The CP model was implemented between January 1, 2014, and April 30, 2015 in a suburban-urban AIM program. Participants included 1,602 individuals enrolled in the AIM program with high rates of dementia, decubitus ulcers, diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease. Participants had a median age of 83 and an average of five activity of daily living dependencies (range 0-6). During the study period, there were 664 CP responses and 1,091 traditional EMS transports to the ED among 773 individuals. Only 22% of CP responses required transport; 78% were evaluated and treated in the home. Individuals that community paramedics transported to the ED had higher rates of hospitalization (82.2%) than those using traditional EMS (68.9%) (P < .001). Post-CP surveys showed that all respondents felt the program was of high quality. Results support the potential benefits of CP and invite further evaluation of this innovative care model.

Access the full study via the National Center for Biotechnology Information, U.S. National Library of Medicine.

Innovative Geriatric Practice Models: Preliminary Data Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program—Preliminary Data  Karen A. Abrashkin MD Jonathan Washko MBA Jenny Zhang BA Asantewaa Poku MPH Hyun Kim ScD Kristofer L. Smith MD, MPP First published: 30 August 2016 https://doi.org/10.1111/jgs.14484

Abstract from the British Medical Journal (BMJ) Supportive & Palliative Care

Objectives As the US population ages and healthcare reimbursement shifts, identifying new patient-centred, cost-effective models to address acute medical needs will become increasingly important. This study examined whether community paramedics can evaluate and treat, under the direction of a credentialed physician, high acuity medical conditions in the home within an advanced illness management (AIM) practice.

Methods A prospective observational study of an urban/suburban community paramedicine (CP) programme, with responses initiated based on AIM-practice protocols and triaged prior to dispatch using the Advanced Medical Priority Dispatch System (AMPDS). Primary outcome was association between AMPDS acuity levels and emergency department (ED) transport rates. Secondary outcomes were ED presentations at 24 and 48 hours post-visit, and patient/caregiver survey results.

Results 1159 individuals received 2378 CP responses over 4 years. Average age was 86 years; dementia, heart failure and asthma/chronic obstructive pulmonary disease were prevalent. Using AMPDS, most common reasons for dispatch included ‘breathing problems’ (28.2%), ‘sick person’ (26.5%) and ‘falls’ (13.1%). High acuity responses were most prevalent. 17.9% of all responses and 21.0% of high acuity responses resulted in ED transport. Within 48 hours of the visit, only 5.7% of the high acuity responses not initially transported were transported to the ED. Patient/caregiver satisfaction rates were high.

Conclusion Community paramedics, operating within an AIM programme, can evaluate and treat a range of conditions, including high acuity conditions, in the home that would typically result in ED transport in a conventional 911 system. This model may provide an effective means for avoiding hospital-based care, allowing older adults to age in place.

Access the full study via the British Medical Journal.

Abrashkin KA, Poku A, Ramjit A, et al Community paramedics treat high acuity conditions in the home: a prospective observational study BMJ Supportive & Palliative Care Published Online First: 04 April 2019. doi: 10.1136/bmjspcare-2018-001746

2019 AIMHI Leadership in Integrated Heathcare Award
Douglas Hooten, Medstar Mobile Healthcare

As the CEO of MedStar Mobile Healthcare, Doug has led and empowered an innovative team of leaders to stretch the boundaries of the EMS role in the larger healthcare system.  This leadership has led to 16 formal agreements with MedStar by various healthcare system stakeholders for MIH services.  Doug is also the co-author of the only book published on the implementation of Mobile Integrated Healthcare programs, ‘Mobile Integrated Healthcare – Approach to Implementation’, published by Jones and Bartlett.

Impact

Doug encourages and facilitates MedStar’s diffusion of information and best practices in the following ways:  

• Hosting over 220 communities in 42 states and 6 foreign nations at MedStar to share MedStar’s experiences implementing MIH services.
• Speaking, or facilitating at more than 70 presentations at state and national conferences on the best practices and lessons learned in MIH program development, implementation, and economic modeling.
• Writing or facilitating the authorship of nearly 30 articles on these same topics.

Biography

Doug Hooten is the Chief Executive Officer of MedStar Mobile Healthcare in Fort Worth, Texas.  He has more than 39 years of experience in EMS, having served as senior vice president of operations and regional director for American Medical Response, CEO of the Metropolitan Ambulance Service Trust (MAST) in Kansas City, and a variety of leadership roles with Rural/Metro Ambulance, Inc. in South Carolina, Georgia, Ohio and Texas.  He has demonstrated considerable expertise in change management, cost optimization, process improvement and clinical excellence.  

Having started his career in EMS as a field paramedic in Conroe, Texas, Hooten holds an undergraduate degree in business administration from Sam Houston State University in Huntsville, Texas and a Master of Business Administration from Rockhurst University in Kansas City, Missouri. 

He recently served on the National EMS Advisory Committee (NEMSAC), and is the immediate past president of the Academy of International Mobile Healthcare Integration.  Doug is also a Board Member for the American Ambulance Association and the Texas EMS Alliance. 

An expert in Mobile Integrated Healthcare, Doug is a co-author of the Jones and Bartlett book Mobile Integrated Healthcare—Approach to Implementation and is a regular speaker for industry conferences.