i am worried. can you send someone to see my...

12/9/2014

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I Am Worried.

Can you Send Someone to

See My Mom?

Kristofer Smith, MD, VP

Jonathan Washko, AVP

Asantewaa Poku, Clinical Data Analyst

Elizabeth Quellhorst, Administrative Manager

Session Code A25, B25

Presenters have

nothing to disclose

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Session Objectives

• Identify the key operational strategies necessary to build programs to

keep high-risk frail elderly from going to the emergency room

• Review lessons learned from a collaboration between an advanced

illness management program and a community paramedicine program

aimed at reducing admission rates for the high-risk frail elderly in the

community

• Understand how to ensure the financial viability of clinical

collaboratives focused on high-risk patients by taking advantage of

health care reform and/or partnering with insurance companies

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Problem Statement

• Seniors with multiple chronic conditions in an advanced

state with functional impairment have frequent

deteriorations in health status which requires meaningful

24x7 clinical responses.

• These high risk, high cost populations have extreme

difficulty getting to traditional outpatient services and

therefore rely heavily on emergency department and

hospital care.

• Interrupting this cycle through at home clinical support

programs could alleviate suffering, improve quality and

decrease cost.

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Complex medical management for more than 1,000 patients in Queens,

Nassau, and Suffolk counties with multiple chronic conditions and functional

impairment

• Interdisciplinary care teams, which include physicians, nurse

practitioners, social workers, and medical coordinators deliver primary

and palliative care in the patient’s home in an effort to:

– Understand wishes of the patient and family (advance care planning)

– Maintain or improve functional status

– Reduce unnecessary utilization or unwanted care

– Increase days at home

– Allow for death with dignity at home

– Care for the whole person: social work and care coordination

Advanced Illness Management

– House Calls Program

Background

House Calls Patients, N= 1071 Age110 Oldest

84 Average

21 Youngest

= 10 patients

69% Female

31% Male

Nassau, Suffolk and Queens counties

* November 2014 Census

Advanced Illness Management – House

Calls Program Background

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• 33% of annually (death and discharge)

Attrition

• 71% of patients who died, died at home in the past year

Death at Home

• 65% of patients have 5 – 6 ADL dependencies

Activities of Daily Living

House Calls Stats*

* November 2014 Census

Advanced Illness Management – House

Calls Program Background

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• Established in 1993, providing air and

ground BLS, ALS, SCT, CCT and 911

services

• 600+ Emergency Medical Technicians

and Paramedics

• Largest health system based ambulance

service in New York Metropolitan area

and one of the largest in the United

States

• Duly accredited by the Commission on

Accreditation of Ambulance Services

(CAAS) and the National/International

Academics of Emergency Dispatch,

Accredited Center of Excellence (ACE)

Program Background

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• Over 110 available response units

across New York City, Nassau, and

Suffolk

• More than 135,000 requests for

service per year

• 24x7x365 Fault tolerant services

• Advanced Medical Priority Dispatch

System with Dispatch Life Support

• Clinician answers every call utilizing

call prioritization & triage system

• All ALS system operates under a High

Performance EMS operations model

• Reliable, clinically appropriate

response time

Program Background

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Unique, Innovative &

Integrated Solution

• Comprehensive Mobile Integrated Healthcare /

Community Paramedicine Program

• Telemedicine

• Centralized Command and Control System

• Integrated into EMS System as a Clinical Safety

Net

• Advanced Analytics

• Integrated Quality Assurance / Improvement

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Comprehensive

Mobile Integrated Healthcare


• MIH Framework– Regulatory Approach

– Specialized Training

– Specialized Equipment

• EMS Operations– Command and Control

– High Performance EMS

– Marginal vs. Specialized Approach

• Clinical– Telemedicine, On Line Medical Control

– Formulary, Diagnostics & Treatment Modalities

– Death at Home with Dignity

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Non-Transport Solution Options

Diagnostics Treatments FormularyExpanded Physical Assessment Basic Airway Management Magnesium Sulfate Ipratropium Bromide

SAO2 Suctioning Solu-medrol Sodium Chloride

ETCO2 Oxygen Therapy Glucagon Diazepam

Blood Glucose Medical Equipment Adjustment Nitroglycerine Fentanyl

Temperature Burn Care Metoprolol Diphenhydramine

Weight Hemorrhage Control Labetalol Midazolam

Vital signs Invasive Tube Assessment Odansetron Morphine Sulfate

EKG Rhythm Interpretation IV Catheter Placement & Removal Dextrose 50% Lorazepam

12 Lead EKG NG Tube Placement & Removal Albuterol

Environmental Assessment Pain Management Tetracaine

Medication Administration Naloxone

In Home Assistance Aspirin

IV Fluids Furosemide

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Transport to ED Required Solutions

Diagnostics Treatments FormularyNone Require Transport Advanced Airway Management (ALS) Atropine

BiPAP / CPAP Dopamine

Severe Hemorrhage Control Adenocard

C-Spine Immobilization Epinephrine

Defibrillation / Cardioversion Calcium Chloride

External Pacing Vasopressin

IO Placement Amiodarone

Long Bone Splinting Diltiaizam

Sodium Bicarbonate

Etomidate

Vecuronium

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Integrating Telemedicine

• In 2014, the Verizon Foundation awarded a grant to the North Shore-

LIJ Health System

• LG G2 wireless devices and lines of service were provided as in-kind

support to allow for secure video conferencing (WebEx) between the

paramedic, OLMC MD, and patient/family during Community

Paramedicine responses

• Launched in September 2014, integration of telemedicine allows for

more accurate assessment and enhanced “physician extender” ability.

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Comprehensive

Mobile Integrated Healthcare Community

Paramedicine Program

• Year One Program Results

– Operational Metrics

– Clinical Metrics

– Outcome Metrics

– Quality of Care & Patient Safety Metrics

– Financial Metrics

Community

Paramedicine

Responses

Time (min)

Average CP

Response time22

Average CP time

on scene65

Average task time 80

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There were a total of 2,889 House Calls patient calls over the course of the first year

Community Paramedicinewas activated for 386 of these calls (13.4%)

88 Community Paramedicine calls (22.8%) resulted in transport to the hospital

Over 60% of the calls occurred during House Calls non-business hours

Operational Metrics

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Operational Metrics

0

10

20

30

40

50

60

70

CP Call Volume by Month

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Clinical Metrics

EMD Coding by Category

abnl labs/vitals

5%

behavioral2%

cardiac4%

catheter issue1%

circulatory/cellulitis/skin8%

dizzy/weak/lethargic/ams/ neuro/dehy/intk or output issues/fever/

diabetes45%

GI/nausea /vomit10%

pain/discomfort/reaction/uti

13%

public assist/no medical concern

5%

respiratory/cough/mucous

7%

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Clinical Metrics

EMD Problem/ Nature Transport Avoidance

0

1

1

1

2

2

4

5

5

7

10

9

15

14

20

42

64

72

1

1

3

1

8

2

7

5

17

22

22

Cardiac or Respiratory Arrest/Death

Back Pain (Non-Traumatic or Non-Recent…

Headache

Overdose/Poisoning (Ingestion)

Unknown Problems (Person Down)

Psychiatric/Abnormal Behavior/Suicide Attempt

Traumatic Injuries (Specific)

Diabetic Problems

Heart Problems/AICD

Convulsions/Seizures

Abdominal Pain/Problems

Stroke (CVA)

Hemorrhage/Lacerations

Unconscious/Fainting (Near)

Chest Pain (Non-Traumatic)

Falls

Unable To Determine

Breathing Problems

Sick Persons (Specific Diagnosis)

Transport Avoided Transported

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Clinical Metrics

EMD Problem/Nature by Non-Transport Type

2

1

1

2

3

5

5

5

8

14

26

22

36

1

1

2

2

3

4

0

7

4

4

11

16

24

1

2

3

2

1

1

1

4

3

2

2

5

26

12 1

22

Back Pain (Non-Traumatic or Non-…

Headache

Overdose/Poisoning (Ingestion)

Unknown Problems (Person Down)

Psychiatric/Abnormal Behavior/Suicide…

Traumatic Injuries (Specific)

Diabetic Problems

Heart Problems/AICD

Convulsions/Seizures

Abdominal Pain/Problems

Stroke (CVA)

Hemorrhage/Lacerations

Unconscious/Fainting (Near)

Chest Pain (Non-Traumatic)

Cardiac or Respiratory Arrest/Death

Falls

Unable To Determine

Breathing Problems

Sick Persons (Specific Diagnosis)

CP: Evaluated CP: Evaluated & OLMC Care Plan ChangeCP: Evaluated & Treated CP: Evaluated/Treated/PronouncmentCP: Pronouncment

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ECHO

•Choking with complete obstruction

•Allergic reaction with ineffective breathing

•Respiratory/cardiac conditions with ineffective breathing

DELTA

•Allergic reaction with AMS

•Breathing problems with AMS

•Breathing problems color change

•Burn ≥ 18% of body area

•Choking with abnormal breathing

CHARLIE

•Abnormal breathing conditions

•Cardiac problems (with history)

•Headache with speech problems

•Overdose with Altered Mental Status

•Stroke conditions

BRAVO•Unknown conditions

•Possibly dangerous trauma injuries

•Non-imminent labor

•Serious hemorrhage

ALPHA •Low acuity response with no priority symptoms

OMEGA•Response level for special referrals

•Poison control center or nurse advice

•Non-priority complaints

Clinical Metrics

Emergency Medical Dispatch Priority Codes

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71.2%

100.0%

78.7%

67.5%

80.5%

73.3%

28.8%

21.3%

32.5%

19.5%

26.7%

Transports avoided Transported

Clinical MetricsTransport Avoidance by EMD Priority Code

0.00%

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62%

12%

57%

63%

48%

26%

26%

6%

35%

26%

24%

32%

12%

8%

11%

27%

38%

1%

82%

4%

100%

CP: Evaluated CP: Evaluated & OLMC Care Plan ChangeCP: Evaluated & Treated CP: Evaluated/Treated/PronouncementCP: Pronouncement

Clinical Metrics

EMD Priority Code by Non-Transport Type

25

1

2

4

2

5

3

16

22

35

32

1

3

1

5

5

19

13

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Medication administration - Intranasal

BVM ventilation

Pain Management

Medication administration - Sublingual

Medication administration - Intramuscular

Hemorrhage control

Medication administration - Oral

Medication administration - Nebulized

Oxygen therapy (blow by/ nasal cannula/nebulizer/trachmask)

Medication administration - Intravenous

IV catheter/saline lock placement

Evaluated & Treated Evaluated, Treated & Transported

Clinical Metrics

Administered Treatment by Disposition

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26

1

2

1

3

1

6

8

10

13

14

15

1

1

1

2

2

1

4

4

1

3

6

4

6

6

Labetalol

Diazepam

Fentanyl

Naloxone

Metoprolol

Glucagon

Ondansetron

Dextrose 50%

Nitroglycerin

Aspirin

Solu-medrol

Morphine Sulfate

Ipratropium Bromide

Furosemide

Sodium Chloride 0.9%

Albuterol (0.083%)

CP: Evaluated & Treated CP: Evaluated, Treated & Transported

Clinical Metrics

Administered Medication by Disposition

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Clinical Metrics

Follow-Up Planning

Non-Documented5%

Scheduled CP follow up

2%

House Calls follow up –

Telephonically14%

House Calls follow up -

Patient Visit24%

No Follow up needed

55%

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Quality of Care & Patient Safety

Avoidable Transports by Presenting Problem

26%

13%

61%

Transports

Non-avoidable transports

Patient/ Family choice

Potentially avoidable ifreceived in home care

6

5

4

3

1

1

1

1

1

0 1 2 3 4 5 6 7

Pneumonia/Resp. Infection

Peg Tubes

Labs needed

Foley Catheter/Pubic Tube issues

UTI

GI/Constipation

Lacerations

Hyperglycemia

Hypotensive w/o IV access

Presenting Problem of Potentially Avoidable Transports

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Reason for Transport # Occurrences Potential Solution

Patient/Family Choice 11 Patient/Family Education

Labs needed 4 I-STAT/ Point of Care testing

Peg Tubes 5 Ultra Sound/X-ray, Training for CP

Foley Catheter/Pubic Tube issues 3 Training for CP

Pneumonia/Resp. Infection 6 I-STAT/ABX/Chest X-ray

UTI 1 I-STAT/ABX/Foley replacement

GI/Constipation 1 Laxative, Training for CP

Lacerations 1 Suture training for CP

Hyperglycemia 1 Insulin

Hypotensive w/o IV access 1 Conscious IO access


RCA to avoid future Transports

34 (38.6%) of the 88 CP transports were potentially avoidable

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Physician Survey Responses

Yes118 (74%)

No41 (26%)

0% 20% 40% 60% 80% 100%

• Death pronouncement

• Reassurance for overwhelmed or distressed caregiver

• Public assist• Patient is on

hospice; has no intention of being hospitalized

• “Patient had large laceration on foot and it would not have been washed and dressed properly (with a pressure dressing) if the Community Paramedic was not there.”

• “The negative neurological exam helped remove possibility of CVA.” • “I was not going to prescribe antibiotics until the evaluation by CP medics

revealed abnormality of skin.”• “The patient complained of being short of breath but her normal oxygen

saturation provided reassurance that she could be treated at home.”• "I was going to order an x-ray, which would have meant waiting 5+ hours

for results. But one leg was actually found to be rotated and shorter than the other, so immediate transport was arranged, avoiding hours of suffering."

Did the information provided by the Community Paramedicine evaluation change your medical management?

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Physician Survey Responses

If the Community Paramedicine evaluation had not been available, would you have advised the patient to go to the ER?

Yes110 (69%)

No50 (31%)

0% 20% 40% 60% 80% 100%

• “I definitely was going to send the patient to the ER if Community Paramedicinehad not been available.”

• “The Community Paramedics’ evaluation gave me more confidence in my plan. I would have recommended that the patient go to ER based on the symptoms described by the patient’s daughter.”

• “I originally was going to have the patient stay home, but then found that she was somnolent and hypoxic so I sent her to the hospital for further evaluation.”

• “Patient was recently accepted onto hospice and wanted to stay home.”

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Physician Survey ResponsesDid video monitoring enhance your evaluation of the patient during the Community Paramedicine response?

Yes59 (81%)

No14 (19%)

0% 20% 40% 60% 80% 100%

• “It showed the intensity of the bleeding from the patient’s trach.”• “I was able to see urine and that the foley was draining despite what the patient stated.”• "Video conferencing allowed me to see my patient pre-Lasix. Since she is my patient, I

was able to see that she was more lethargic than usual, despite the paramedic's report that she looked 'fine.' I could see her change from baseline status. She appeared more energetic after the Lasix was given, and she was able to stay at home."

• "I was able to see on video conference that the patient was flat in bed, and recommended he be raised HOB to help with cough. I decided not to prescribe Albuterol."

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Patient Satisfaction Survey Results

• 107 surveys were mailed to the patient home following a Community Paramedicine (CP) response from 9/17/14 to 12/5/14.– Surveys were not mailed to patients who passed away.

– Patients who had multiple CP responses within a 1-3 day window received one survey.

• 32 surveys were completed (30% response rate)– 5 (16%) were completed by the patient

– 27 (84%) were completed by a family caregiver

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1 (3%)2 (7%) 3 (10%) 2 (7%) 2 (7%) 2 (7%)

28 (93%) 27 (90%) 28 (93%) 28 (93%) 27 (90%)

0%

20%

40%

60%

80%

100%

Overall, I wassatisfied with myCP experience.

I would use theCP service in afuture medical

emergency.

The CommunityParamedics

delivered high-quality services

and care.

I was satisfiedwith how the on-call House Calls

provider andCommunityParamedics

managed mymedical issues.

My goals formedical care

were accountedfor in the

treatment plan.

Neutral Agree Strongly Agree

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• “Could not have asked for more. Could not be more grateful for be in the House Calls

Program.”

• “I (the caregiver) was completely satisfied with the doctor and Paramedics in the prompt

care my father received, from the time the doctor called me with the results of his blood

work, to his care by paramedics, to his trip to the ER.”

• “I was very impressed with the program. I am an RN and I truly appreciate the level of

professionalism and caring that was shown to my father. Bernard (our paramedic) made my

father feel at home immediately. This is a wonderful program.”

• “I am the daughter of an elderly patient. The House Calls program and Community

Paramedics have been an absolute lifesaver - for all of us. With your amazing care, we

have been able to keep my mother at home, out of the hospital, comfortable, and incredibly

well cared for.”

Dialed 91123 (62%)

Went to the Emergency Room for

evaluation or treatment11 (30%)

Waited to see if I

got better3 (8%)

0% 20% 40% 60% 80% 100%

If the Community Paramedicine Program did not exist, what would you have done during your medical emergency?

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Outcome Metrics

Admission Rate of Transported Patients

100% 100%

88%83%

80%83%

69%

100%

50%

100%

92%

82%

50%

60%

70%

80%

90%

100%

110%

November2013

December2013

January2014

February2014

March2014

April 2014 May 2014 June 2014 July 2014 August2014

September2014

October2014

CP Transport Inpatient Admission Rate Avg. CP Transport Inpatient Rate

Non-CP Transport Inpatient Admission Rate Avg. Non-CP Transport Inpatient Admission Rate

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Community Paramedic Program

Financial Metrics

• Costs based on leveraging existing CEMS infrastructure

• Calculated using fixed and variable costs per visit

• Approximately $200 per visit @ 1.25 hours which

includes:

– Vehicle, maintenance and fuel

– Salaries, wages and benefits

– Medications, supplies and equipment

– Dispatch services and specialized software

– Integrated call services

– Other general expenses

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Payment

Avoidance

Estimations

Marketplace Challenges

Government Payment

Reductions

Increased Consumerism

and Price Transparency

Payer Mix Shift to Gov’t Payers

& Exchanges

Increased Provider

Competition

Inpatient Volume & Case Mix Declines

Downgrades/Denials-

RAC/MAC

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Readmission Penalties

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Strategy

Health System Strategy

Strategy

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Risk Based Contracts

Program Type Description

Full Risk• Receive all or portion of premium.• Responsible for total cost of care.

Shared Risk

• Share in upside/downside savings/losses relative to pre-established spending target.

• Responsible for all or portion of medical spend.• Quality Gate

Shared Savings• Eligible to share upside savings with payer relative to

pre-established spending target.• Quality Gate

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SourceAdvisory Board. The Essentials of Risk Based Contracting

Margin Impact

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Program successes to date

• 24x7 on-demand Community Paramedic response

effectively and efficiently fills care gaps in the home

• Significant decrease in transports to the ED yielding

subsequent payment and cost avoidance

• High patient satisfaction levels

• Zero adverse clinical outcomes

• Low cost of services compared to acute care setting

• Opportunities exist to lower transport rate even

further

Comprehensive



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Program challenges to date

• Physician understanding and adoption of EMS

capability and scope into workflow

• Scope of practice / formulary limitations

• State regulatory hurdles & limitations

• Payer source (internally funded R&D project)

• Data integration amongst disparate systems

Comprehensive



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