Reducing Unnecessary Emergency Department Visits: The Case for Mobile Integrated Health/Community Paramedicine

According to a position paper released by the National Association of EMS Educators (NAEMSE), the top concerns of CEOs of several major healthcare organizations are improving ambulatory access and developing innovative approaches to expense reduction.(1,2) Another recent publication found that 48% of the payers and providers who responded to their survey listed one of their top priorities as the need to revamp care delivery models. Items that were seen as even more important were the need to optimize operational processes (50%) and the need to reduce total cost of care (61%).(3) This raises the question: could there be a model that addresses many, if not all, of these needs?

Mobile Integrated Health

The answer is yes. A mobile integrated health/community paramedicine (MIH/CP) model could be the solution to the problem through its unique ability to stand in the gap for both patient and provider. This model is best described by the American College of Emergency Physicians Mobile Integrated Health/Community Paramedicine Task Force as “a new model of community-based healthcare service delivery that often primarily uses emergency medical services personnel and systems to provide acute medical care, coordination of services, healthcare maintenance, post-acute care, and prevention services to patients.”(4) The concept was first introduced in the early 1990s in the EMS Agenda for the Future(5) and was first implemented in other parts of the globe, beginning with Canada in 1999, progressing to the United Kingdom in 2004,(6) and finally presented at a development meeting in Nebraska in 2007.(2)

Since then, the journey toward establishing government funding and payer support has been slow, despite increasing evidence that implementation decreases hospital readmission rates and improves patient satisfaction.(7) A survey conducted by the National Association of Emergency Medical Technicians (NAEMT) in 2017 revealed that there were 200 EMS agencies nationwide that reported offering MIH/CP services.(8) Many types of programs fall under the umbrella of mobile integrated health; some of these include traditional community paramedicine, 9-1-1 nurse triage services, alternative destination transport systems, station-based clinics, and house-call physicians.(9) Determining which type of service model would best meet the needs of your local community can be accomplished by performing a care gap analysis and a formal community needs assessment(9,10) Potential sources of data to accomplish these ends include EMS data, hospital admission/discharge data, population demographics, emergency department (ED) data, focus groups, stakeholder input, and telephone and mailed surveys to partners and the community.(8)

Startup Costs

Once the care gaps have been identified, steps can be taken to address them. The process of starting an MIH/CP service could take anywhere from six months to two years, according to the NAEMT survey. Additionally, startup costs may be as high as $300,000.(8) The reported startup costs were to include payment for staff time for planning and training, costs accrued through use of consultants, and costs for purchasing equipment and vehicles.(8) Sources of revenue for these programs range from fee-for-service, fee-for-patient, and fee-for-enrollment to shared savings with partner organizations. Moreover, 14 states offer Medicaid reimbursement for services, and some commercial providers, such as Anthem Blue Cross Blue Shield (BCBS), also offer reimbursement.(8) Although the process has been slow, strides are being made to ensure that long-term, sustainable funding exists. Additional resources for agencies wishing to start an MIH/CP program can be found in the toolkit provided by NAEMT.(11)

To further prove the utility of these programs, consider the CMS Merit-based Incentive Payment System/Accountable Care Organization quality payment program for value-based care. According to Kaiser Health News, 80% of the hospitals evaluated by CMS in 2018 will face penalties of up to 3% of their Medicare payments.(8) Likewise, in 2017 the healthcare system first encountered push-back from commercial payers, specifically Anthem BCBS and UnitedHealth, which threatened to deny certain ED claims and to scale down the more expensive claims if they deemed that the visit was nonemergent or the code was not justified.(8) This emphasizes the need to expand the horizons of healthcare service delivery, and MIH/CP is aptly situated to address both hospital readmission rates and unnecessary use of the ED.

CMS Quality Measures

In order to fully appreciate the value that MIH/CP programs bring to the table, a quality measures reporting strategy has been initiated; it can be found in the MIH/CP toolkit.(11) It outlines the quality measures that are most important to CMS, that are mandatory to be reported in order for a program to qualify as a MIH/CP program, and that are most important to physicians and healthcare partners.(12) By establishing this system of reporting, greater transparency is achieved, and appropriate steps forward can be made in terms of quality improvement and quality assurance.

Despite all of the practical benefits these programs have demonstrated, one potential concern regarding their acceptance is whether or not they overlap with already established out-of-hospital services, such as home healthcare and hospice. However, many programs have found that these services can be marketed to complement each other. The example given in the survey was that for post-acute care, EMS practitioners within the MIH/CP framework can be dispatched to the home within 24 hours of discharge to discuss discharge instructions, conduct medication review, and ensure the patient’s questions are answered.(8) By making contact with the patient between the time they leave from the hospital and before the home healthcare nurse arrives, the EMS practitioner can intervene during that critical phase when a patient is transitioning from inpatient life back to independent home life.

Pillars of Value-Based Care

Transition of care, chronic care management, annual well care visits—these can all be sources of potential drains on institutions’ funding from CMS and the QPP. However, when viewed through the lens of an MIH/CP program, these can be seen as opportunities for growth and value-based, patient-centered care. Not only that, but the NAEMSE advocates for the incorporation of clinical education covering chronic alcohol or drug dependency, treatment of overdoses, and wellness strategies to promote recovery for patients suffering from substance

Regardless, the future of healthcare depends on innovative and integrative ideas to optimize healthcare delivery to those who otherwise would struggle to obtain it. The incorporation of MIH/CP programs that fit the community needs assessment for specified populations should be on the frontline in this shift in healthcare delivery.

References

1. Castellucci M. About 30% of emergency department visits by patients with common chronic conditions are potentially unnecessary. Modern Healthcare. February 11, 2019. www.modernhealthcare.com/article/20190207/TRANSFORMATION03/190209949 . Accessed February 15, 2019.

2. Raynovich B, Nollette C, Wingrove G, Wilcox M, Mattera CJ. NAEMSE Position Paper on community paramedicine and mobile integrated healthcare. JEMS. January 17, 2018. www.jems.com/ems-insider/articles/2018/january/naemse-position-paper-on-community-paramedicine-and-mobile-integrated-healthcare.html . Accessed February 19, 2019.

3. Shared challenges and shared opportunities: 2019 top payer-provider priorities. Modern Healthcare. February 12, 2019. www.modernhealthcare.com/article/20190205/SPONSORED/190209972 . Accessed February 19, 2019.

4. Mobile integrated healthcare/community paramedicine (MIH/CP) Primer (Rep.). American College of Emergency Physicians. June 2016. www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/ems-and-disaster-preparedness/ems-resources/mih-cp-primer-2016.pdf . Accessed February 19, 2019.

5. Emergency Medical Services Agenda for the Future. EMS.gov. July 6, 2010. www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf. Accessed February 15, 2019.

6. Zavadsky M, Lawrence R. Learning from international mobile integrated healthcare initiatives. JEMS. June 9, 2015. www.jems.com/articles/print/volume-40/issue-6/features/learning-from-international-mobile-integrated-healthcare-initiatives.html . Accessed February 19, 2019.

7. Roeper B, Mocko J, O’Connor LM, Zhou J, Castillo D, Beck EH. Mobile integrated healthcare intervention and impact analysis with a Medicare Advantage population. Popul Health Manag. 2018;21:349-356.

8. Zavadsky M, Washko J, Babson M, et al. Mobile Integrated Healthcare and Community Paramedicine (MIH-CP) 2nd National Survey. J Emerg Med Serv. 2018;1-32. www.naemt.org/docs/default-source/2017-publication-docs/mih-cp-survey-2018-04-12-2018-web-links-1.pdf?Status=Temp&sfvrsn=a741cb92_2 . Accessed February 15, 2019.

9. Staffan B, Swayze D, Zavadsky M. Using data and outcome measures to show economic sustainability of mobile integrated healthcare programs. JEMS. May 8, 2017. www.jems.com/articles/print/volume-42/issue-5/features/using-data-and-outcome-measures-to-show-economic-sustainability-of-mobile-integrated-healthcare-programs.html . Accessed February 15, 2019.

10. Pearce EA, Cody MD, White CC IV. EMS-based urgent care in the Ramah (N.M.) Navajo Reservation. JEMS. May 1, 2018. www.jems.com/articles/print/volume-43/issue-5/features/ems-based-urgent-care-in-the-ramah-n-m-navajo-reservation.html . Accessed February 15, 2019.

11. MIH-CP Program Toolkit. http://naemt.org/initiatives/mih-cp/mih-cp-program-toolkit . Accessed February 19, 2019.

12. Mobile integrated healthcare program: measurement strategy overview. NAEMT. November 1, 2016. www.naemt.org/docs/default-source/community-paramedicine/mih-cp-toolkit/mih-metrics-for-community-health-interventions-final-for-release-11-1-16.pdf?status=Temp&sfvrsn=0.7422326258001202. Accessed February 19, 2019.