By assessing and stabilizing at-risk patients, paramedics can avoid unnecessary emergency department visits, generating savings of approximately $1,900 per case.
Back in 2014, leaders at Commonwealth Care Alliance (CCA), a not-for-profit healthcare organization and integrated delivery system that cares for dual eligible beneficiary members in Massachusetts, set out to reduce unnecessary use of the emergency department (ED), which its members were 300 percent more likely to visit than the general population. CCA partnered with a local ambulance company to pilot a mobile integrated health program in eastern Massachusetts that expanded paramedics’ traditional scope of practice.
“Rather than go to patients’ homes to stabilize and transport, the specially trained paramedics go to patients’ homes and stabilize, assess, diagnose, and treat patients in their homes,” says Donna Moore, senior vice president of mobile integrated health at CCA.
So far, the results of the program have been promising: According to the latest 12-month period ending June 30, 2018, the pilot program has helped safely prevent an ED visit or hospital admission 82 percent of the time, saving approximately $6 million.
How It Works
By law, paramedics are required to take sick patients to the hospital, but the state waives this requirement for paramedics participating in the program. As part of the pilot, CCA trained community paramedics with a local ambulance company to make “house calls” to members between 6 p.m. and 1 a.m.
Working in collaboration with CCA’s primary care teams, the paramedics perform physical assessments, conduct real-time diagnostic tests, and administer medication when needed. They also work with the on-call physician to review, revise, and approve the paramedic’s recommended course of treatment. As part of the agreement, the ambulance company receives a monthly fee from CCA.
CCA providers refer their patients for a mobile health visit, but members also can self-refer by calling CCA’s 24-hour member services line, staffed by nurses who follow defined protocols to triage patient complaints. Those who require true emergency care are referred to 911, while others are ranked by clinical acuity, enabling paramedics to visit members with the most urgent needs first.
In recent years, the practice of community paramedicine—using specially trained paramedics to assess and stabilize at-risk patients, thus avoiding unnecessary ED visits and hospitalizations—has gained some traction. For example, organizations like Geisinger, Danville, Pa., and North Memorial Health Care, Robbinsdale, Minn., are testing similar approaches to reduce costs and improve quality.
Creating a New Role for Paramedics
To participate in CCA’s mobile integrated health program, community paramedics complete 300 hours of training on topics that go beyond their traditional training, such as wound assessment and care. They also learn about managing multiple chronic conditions, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma, and diabetes. This helps paramedics learn what exacerbations of these overlapping conditions might look like in the patient population.
In addition, paramedics learn how to assess and stabilize patients with behavioral health conditions like depression that often accompany other chronic medical conditions. Prior to participating in the program, paramedics’ skills and knowledge are assessed by a CCA medical director, supervisors, and peers during a simulation program.
In 2018, paramedics logged almost 1,000 visits to 600 unique CCA members in the pilot. During a typical 80-minute visit, a paramedic might see a 54-year-old male with stage 3 CHF and moderate COPD with trouble breathing. After consulting an on-call physician by phone and reviewing shared electronic health records (EHRs), the paramedic assesses, treats, and stabilizes the patient. By receiving care from the paramedic, the patient remains at home and avoids a costly, and inconvenient, visit to the ED.
Moore estimates the average savings of a safely avoided ED visit at approximately $1,900. As previously mentioned, the program has safely prevented an ED visit within 72 hours of a home visit approximately 82 percent of the time.
Each month, John Loughnane, MD, CCA’s chief innovation officer, and the team review clinical outcomes like ED utilization to ensure appropriate use of the paramedic service and identify areas for improvement. In addition, leaders at CCA review and share clinical, satisfaction, and cost data with providers via a simple scorecard. “The key to success is being able to share the data and information after the intervention,” Moore says.
Each quarter, CCA physician leaders round with paramedics to identify potential care gaps and possible training opportunities. Moore says these rounds also help clinical leaders monitor the proficiency of each member of the care team.
Heeding Lessons Learned
Moore offers the following tips for other organizations looking to launch a community paramedicine program to reduce unnecessary ED visits and hospitalizations.
Find a well-respected, high quality EMS company to partner with on a pilot. “You need to have high-quality partnerships with a network provider that you know has the proficiency that you can trust,” Moore says. “They are the face of the service.”
Include effective communication as part of paramedics’ training. Paramedics learn how to communicate with on-call clinicians, patients, and families as part of their training. Topics covered include motivational interviewing and empathic listening.
Create an efficient triage process at the front end. CCA nurses use a set of clinical eligibility criteria to determine which members are best suited to be seen by paramedics and which should call 911. The nurses utilize industry-standard triage protocols that have been customized to facilitate intake.
Provide physician oversight. CCA uses internists, ED physicians, and family practitioners to medically supervise paramedic care in the home.
Develop a solid aftercare protocol. After members receive treatment from a paramedic, CCA attempts to follow up with the member three times within 12 to 24 hours to verify patient status and assess satisfaction. CCA also informs the member’s provider of the visit and visit outcome. “We call this follow-up and follow-through,” Moore says.
Consider the patient experience. CCA uses a 12-question phone survey to gauge member satisfaction within 30 days of a visit from a paramedic. In 2018, more than 90 percent of 400 patients surveyed said they would be willing to use the service again. “When you go to the home, the patient and family are so grateful that you are there—they don’t expect providers to make house calls,” Moore says. In 2019, CCA plans to measure provider satisfaction with the service, too.
Don’t underestimate the amount of time it takes to change behavior. “We’re intentionally trying to disrupt the well-worn tracks to the ED that people use even when they know they are not having an emergency,” Moore says. Getting members to change how they approach urgent situations that can be treated by paramedics takes an investment in relationships built on trust, she says.
Expanding the Program
Moore estimates the return on investment for the mobile integrated health program is approximately 275 percent, net of program cost. This translates to cost savings for the Commonwealth of Massachusetts and taxpayers, since most care provided by CCA is paid through capitated Medicare (CMS) and Medicaid (MassHealth) payments, Moore says.
In late 2018, Massachusetts issued new regulations that will allow CCA to expand its program from pilot status with restricted hours and geography to a statewide program that operates around the clock. To support this expansion, CCA has partnered with EMS companies that have experience with mobile health and can scale with CCA.
As CCA rolls out its expanded program, Moore and her team will look to cultivate buy-in among providers by engaging them early in the process and sharing outcomes data regularly. “We’re not here to disintermediate providers—we’re here to be accretive to them and be an alternative available to serve their patients,” Moore says. “That is the trickiest thing—making sure that providers see you not as a competitor but as an ally providing a new solution that they didn’t have before.”
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.
Interviewed for this article:
Donna Moore is senior vice president of mobile integrated health, Commonwealth Care Alliance, Boston.